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Joaquin County (� <br /> Fr(� nt Tnmental Health Department SITE <br /> 3 4 East 'r Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> NAbBW#R:F,g ij209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> PER""T/SE1*61I Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made In compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location_ EI lDoro-c-1 Assessors <br /> W�u Cross acity_Sia�klTln zip 'L720y Parcel# 139-oz0-0( <br /> PROPERTY li•l��( OC�jG(,�C.(1%L • ' <br /> Ownerr,�tiF i t� c Address H ZI-A2 U educlty.=�ZIp.T57_,gj4hone# {- <br /> C-57 Contractor_ aSCC�CA(a- Address 3G3;?om c Circle CltylZaac &rcc1b0p Z7o Lic#--1}5/Ophone#9/6-63S-ll(,- <br /> Consultant/Sub Cntr SCc r 61lern4hun61 Address3011- Ll4yre_Za CItyR"r'r+�/r.Ao+FLic# (oSH498 Phone#9/6-ger-O 400 <br /> GIS Coordinates:X—/2-I,Zyjd ;l 2- ,Y 31--%- /'66Jrd$ ,Township �LN Range 15 Sec �g <br /> tion <br /> WORK TO BE PERFORMED, <br /> , NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> D SOIL BORING# a OVER-BORE. DIAMETER <br /> WELL#0 5-1 tt�t1 S- ka> 6. a PRESSURE GROUT <br /> a•Other GROUT SPECIFICATIONS f-- <br /> COMMENTS: - C <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS V1 <br /> u �-} <br /> ()MMONITORINGHOLLOW STEM DIA.OF BOREHOLE p MULTIPLE CASINGS Q MUL71-LEVEL WELL CASING DIA: 3 <br /> �_ >! <br /> o EXTRACTION l)AIR HAMMERIDRIVEN CASING THICKNESSSr kecU-�W66YPE OF CASING: D STEEL JKPVC BOTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3K Ct-1-. TREMIE TYPE TO BE USED: ,AUGERS a HOSE <br /> $,AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: U Yes Ir No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') -' <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS Mg n I- l IJP n S-- --n-Q- i I- <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH SID— RBOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /.)n (if YES,list specifications in comment section) <br /> COMMENTS: <br /> c' <br /> r <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. d <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County�Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x - �`-'4��- �v �— Title/Company 5�-C-P 'Sr-t cF j'k'-' 'i rrnc'j <br /> Print Name Vl(-'rvri Date o2- I(o� bs <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1(4 -.1 A an& (113ai <br /> WORK PLAN DATED: . z1ZC�OI <br /> Application Accepted By_�cy Date Issued �rea 6 Z I <br /> Grout Inspection By ls�-yw.n c.r.. Date S Final Inspection By r1. Date f O <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED I CHECK# REC'D BY DATE PERMIT'/SERVICE REQUEST# INVOICE <br /> 3501 `b�.ob 613s`I1 a3 d5 SR# <br /> C-57_ W--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> ERD 29-02-001 <br /> 02104 <br />