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FILE COPY <br /> San Joaquin County <br /> Environmental Health De artmentSITE <br /> " 304 East Weber Avenue,3rd Floor, Stockton, kMITIGATION <br /> li f, <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/chd UNIT IV <br /> • c/Foa+`"• ►ls���D32 AM II 4 O , (� Rpw <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DA <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 compliancewith San <br /> Joaquin County Development Title Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> L/fi�T �J/d �jpN�O�A`0�!7" Assessors <br /> WELL Location lay?/ 4474T O—e! �''' Cross Street TOQO sg City Zipg�Parcel# <br /> PROPERTI �-x.� <br /> Owner G�7J��,/Of )���� Address �0 -S��✓Z'nY�J�, City ,�� ZlP / Phone# 2o`� 9 '� /'-Z <br /> C-57 Contractor WM&4MW k41- 4,Y Addreas fa 2.1u4 A2 �C/ity� 0�1 Y��Zip!7__/ (Phone# 70J��y yj00 <br /> Consultant/Sub Cntr ress 117 /Gd QLOKfl City 60z.D0✓O Lic# Phone# 0✓6 dweyoo <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERF <br /> 'NEW WELL ORI (CPT GEOPROBE,HRYY ROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BO G#�P'/O f NY'7I aOVER-BORE. DIAMETER <br /> Q��y,OILL# 1]PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: Z Cif/ iS �itol�iyf�/y�f?'� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING a HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: B STEEL 0 PVC BOTHER: <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /S TREMIE TYPE TO BE USED: B AUGERS a HOSE <br /> a AIR SPARGE/OZONE *USH POINT(GP or CPT)GROUT SEAL PUMPED: Wes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,SOIL BORING E HAND AUGER GROUT SPECIFICATIONS A�F/IT C� <br /> N OTHER: n OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX, or E STOVE PIPE <br /> CONDUCTOR CASING PROPOSED G (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 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, les gnRegulations, and all applicable California State Laws. ` <br /> Signed / j �f� /.',. Title/Company ✓7t11�r'✓T f/c- dvc4o�f1�1r7�Jd'D /�yG�I� <br /> Print Name G Gl�� Nr` 5 Date <br /> DEPARTMENT USE ONNL�Y�/�� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /(c, 47, <br /> �gn^'rr"""`� 47r <br /> WORK PLAN DATED: IO —/S -031 <br /> Application Accepted By Date Issue _ Area t-10 s <br /> Grout Inspection By <br /> Date Final Inspection Lr- e .Data <br /> Destruction Inspection By Date Tu 4 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY D"PERMIT REQUEST# INVOICE <br /> 2 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/30/2003 <br />