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• • FILE COPY <br /> �oPq u'.. oe o Joaquin County <br /> N• °` ��� ntal Health Department SITE <br /> 4 East Weber Avenue,3rd Floor, Stockton,CA 95202 MI?'iGATION <br /> Ir 34j�68134QY� : (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> ENVIRONMENT tpermitApplication <br /> PER MTIREPU � <br /> NO -REFU E 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 /> Assessors <br /> WELLLocation 5% &,jk aerl(MI-d //41rossStreet e9kr^4) City IyJ ip fL LParcel# 0 <br /> r/1 <br /> — <br /> OROPE�LSCQVI(ey CO. Address /j, ity41'.', Zip pyzsz Phone# <br /> / d .(, /1 <br /> C-57 Contractor r!'pQ /_ /^� Addr��esslI SaI I r� � 0�1�-;0A City�7f0'YJ Zip J0;9 Lic# hone# f•31 <br /> Consultant/Sub Cntr C(ea�.j ao'.P "b&As 6' � City,ALA --Iwic# Phone# ltr 74 d 3//L <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> D\NEW WELL/BORING (CPT, OPROBE YDROPUNCH,HAND-AUGER,OTHER ) p DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# n-7 a PRESSURE GROUT <br /> D-Other GROUT SPECIFICATIONS <br /> .COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING O HOLLOW STEM DIA.OF BOREHOLE V MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> CKNESS <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THI _TYPE OF CASING: O STEEL ()PVC E OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL — TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE *PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTE: AXIMUMM FREE-FALL DEPTH IS 30') <br /> ]SOIL BORING - u HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I herebAcertify edthis application and that the work will be done In accordance with San Joaquin <br /> Countegulations,and all applicable California State Laws. /Signed x Title/Company r-t a °�' ) I `'Print NaDate I fe T <br /> DEPARTMENT USE ONLY <br /> ��, n Gods` 29-Sd <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date Issued Area a <br /> 41 <br /> Grout Inspection By Date Final Inspection B ate <br /> Destruction Inspection By Date <br /> 14-- <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# PAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ZRo ZI bo 3 2z sR# DD l D <br /> C-57_ WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit- Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />