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Joaquin County • FILE COPY <br /> ` Environmental Health Department SITE <br /> H 304 East Weber Avenue, 3rd Flodr, Stockton,CA 9520 fiECEW� <br /> � IGATI(;N <br /> q ,P (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEFFD FEB 0 '12 r <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described: ' 112N cC(ENT�Hf HEALTH <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environments la•Ith�D��ttiri�A�4E� �n compliance with San <br /> WELL Location`0 y/, &' '17 f- �yjv e, Cross Street iii p�NOC, City�7 Zi _ Assessors <br /> `� _ p y 21 Parcel#_ZC�–/7_0–O ij <br /> PROPERTY <br /> Owne �l1��iSSo Address 30`l5" '1 ej4itisulc- <br /> nsult – � � Jati City 56i � Zip $'2- <br /> phone# �– <br /> s3C-57 Contractor& D,01; Address 9b � stidn4cd Cit �� ��� CLPVJic �% one`l#� <br /> iCG <br /> nt/SubCntr(Ga6ria <br /> City 5cm.cryv. Lic# N4 Phone# 'tp – ? <br /> GIS Coordinates:X )JA .y— Township 1 N Range b Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL#. A4 Il/ –1:!2 0 PRESSURE GROUT <br /> p"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> P"MONITORING STEM DIA.OF BOREHOLE <br /> _a�r p MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSC (ti TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ' -PREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes �!o (NOT MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS a,,--J\�NL = CC'G1•te✓L'� C jt,( J,/.p <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH11 OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING PROPOSED /J (if YES,list specifications in comment section) <br /> NOTE: OFFSIT ORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin s I g ations, and all applicable California State Laws. <br /> Signed x �!� f Title/CompantoapA- Zrw_f_ ter_/ <br /> Print Name Date 7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3o I I W . <br /> WORK PLAN DATED: DPS 14, 2c�oV- <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection Dale <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> LACCOUNiTINiGONLY: AID# FAC# <br /> EE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> MVS S°l Zoo8l L' Z.Z-05 SR# � <br /> C-57 ✓ WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 0'-fat <br /> EHD 29-02-001 <br /> 9/30/1003 <br />