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• • FILE COPY <br /> yQ, San Joaquin County B ECC ITE <br /> A Environmental Health Department L� <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 NOV MITIGATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.co.san-joaquin.ca.us/ehd 4 2005 UNIT IV <br /> q<rke`N`9' ENVIRONMENT H <br /> EAtfM <br /> NON-REFUNDABLE PERMIT EXPIRES 1YEAR FROM DATE ISSUEWERMIT/SERVICES <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 /> Wfsr <br /> -z n Assessors <br /> WELL Location 1Z3S3 1t7t/A4)Y 1� AD Cross Street WfAJDeR50AjCity TA Zip Parcel#209•/60-/2 <br /> ROAD Huvsg <br /> PROPER �p �• ff11 ' <br /> Owner WARI( COAIMVUIT7£S Address•3/20 /RACY BLVD City /T&a Zip 374 Phone#,109-9'36•/5'60 <br /> C•57 Contractor ✓a W 17RILL/Alm r/uCAddress lop Ynru 57-/±O.deA ylC City &LL7YKJ Zip 9r. /) Lic# Syfti Phone# 916-���-4100 <br /> ` es9• W'D904 <br /> Consultant/Sub Cot ewhop 1ARrN eeN./4AddressIj!r / AJIL WLs'T 6'IPCity JlDCKTO/JLIC# Phone#&09-e737/-051� <br /> s0yrc z <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: `J <br /> p NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) g DESTRUCTION (choose type below) <br /> 0 SOIL BORING# .(^rt, /0 OVER-BORE. DIAMETER <br /> 0 WELL# •'V -<PRESSURE GROUT <br /> O'Other - GA. <br /> OUF SPECIFICATIONS <br /> COMMENTS: A(97-90Y !Al e4 / OYTIAM- L L oZ£- W-14 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_. <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: p STEEL ' PVC p OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS NCA <br /> OTHER:WATER 0 OTHER APPROX.BORING DEPTH s15 ' p BOLTED TRAFFIC BOX orpl:STOVE PIPE <br /> l.�UALlTY CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: MW-INA 1,usTALL£11 UAlD£R FFgg rr SROOH16-.5.2 <br /> NOTE: OFFSITE BORINGS 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 Ordina es s a e ulat'ons, and all applicable California State Laws. <br /> 7T/ � �/ p y <br /> Signed x s. d a c T Title/Com an _�oaDn e _j /4 y �el4WLG6le S rwG <br /> Print NameL/U E / yL t K PF Date <br /> �i <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 17/0 3 41 ��"`Si_ (i✓�Gy4�— �Q <br /> WORK PLAN DATED: U <br /> ./ <br /> �?fL <br /> Application Accepted By Dale Issued .'i"D Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS .l -0 Gq j,6 <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2 �� coo. fyoBSou U 1 sR# 0(% <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/30/2002 <br />