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SAN JOAQUIN COUNTY SITE <br /> ONMPN AP HEA Tfi PPA. ` T MITIGATION <br /> 304 East Weber AN en e, 3d Floor, Stockton, CA 95202-270 <br /> (209)468_3449-Far: 209)468-3433- fir u-A,,A,.co.san-joaqttiii,ca,us/ehd <br /> WELL <br /> MaW.R—EFUNDABLE PERMIT EXPIRES 1 YEAR F C9 i1 C}ATE LSSIJEL <br /> Application is hereby made to San Joaqui aunty for a permit to construct and/or install the work described, This a pficacrn its made in cc)ix p fiance with San <br /> Joaquin County Development Titte,Ch ter 9.1115.3 and the Standards of San Joaquin County Environmental eal"parenent. <br /> tin #CC t l T A " CrossStreet C Assessors <br /> L L » <br /> ITC I"i x Cid t` E " i ita " . Parcel# <br /> PROPERTY Owner `C ION F,T fkO Address.500City t ` tl dip, Phone## 1 <br /> C-57 Contractor M(TCfIELL QAI%.Ljjj(r Address 0618 MjL.Ajjo y Cityli,ANCHO Zip_9j6j0Uc#_ I Phone i" t-3S83 <br /> Coiasultant 1 Sub Corr A 4 Address �0, 0 X City C tl _Lic# E Phone#A_91 r <br /> MTIET <br /> GIS Coordinates;X Ii %Ty j.___w ,,To' aship_ Range----Section <br /> ICKTQ EPE RMEt), <br /> NEW WELL!BORING{CPT,GEC) ROBE,HYDROPUNCH,HAND-AUGER,OTHER-) li DESTRUCTION{choose type o <br /> SOIL BORING# � [I OVER-BORE-CIA EIS—_ <br /> III WELL iI PRESSURE C ' <br /> D*Other. Grout Specifications:_ <br /> DLPE rELL LNSTAL TION TYPE ONSTRUCTION SPECIFICAT ON S <br /> MONITORING j HOLLOWSTEL LTIA,OF S )f E 3CtL .0„_ MULTIPLE CASINGS?ti YES #NO ELL.CASING IA;,;*- <br /> EXT GTION II AIR HAMMER/DRIVEN CASING THICKNES ( STEEL j P a O`HE' <br /> VAPOR ROTA Y DEPTH OF GROUT S_ L � r ff� � � ETC.)LSE U 0664 a HOSE <br /> IR SPARGE H POINT GROUT SEAL.F'IJf MU E-FALL IS 30') <br /> OIL.BORING HAND AUGER GROUT”SPECI I AT It�t S: E <br /> OTHER: � THEf APPROX.BORING CtEI� Ii # 1 t LTE f IVIG BOX or STOVE PISTE <br /> CONDUCTOR CASING PR POS ? 0 (if YES, st effimabons her <br /> *CJ IEN : REVISED WCC <br /> NOTE: OFFSITE BORING REQUI ACC SS ORE ACHMENT PERMITS. <br /> CALL THE IV I SPE OR 8 ORKIN HO RS IN VANCEALL REQUIRED INSPECTIONS. <br /> I h reb certify that I h rep ed this a lie on and tha c rk will be done in accordance with San In <br /> County odes and tion and all applicable California State Laws. <br /> Signed x Title/Company • N T' i' <br /> Print Name Lia <br /> D RTMENT USE ONLY <br /> IT I NIT IV FILE, DESS: <br /> WORK E ' er <br /> UL 2 2 200 <br /> Ap ilicatio Accepter S w _ Date Issued__4/1C/> � Area_ <br /> Grout Insp 'on Sy � D to� Final Inspection y <br /> Destruction a <br /> In `on By � at ._ <br /> COMMENTS TS!C NDTHONS, <br /> ACCOUNTING G ONLY: AIC# FAC## <br /> E CODES FEE INFO I LAN MITTED CHECK# LEC>C RTC DATE PERMIT t SERVICE REQUEST# INVOICE <br /> -30 <br /> PLY-- <br /> C-57— W -WAVIER C-57Letterof Authorization to sign p rmiEncroachmenthoc w- <br /> EHD 29.02-001 WELL PERMIT SITE <br /> 8/2712003 <br />