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v <br /> San Joaquin County COPY <br /> ?Vj <br /> ronmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton C'A�'9� r_ {� �y f4�+ MITIGATION <br /> U <br /> ' +''ir �f Il <br /> (209)468-3449 Fax (209)468-3433 Web www sjgflo�v ol1rjg/ehr�d �A UNIT IV <br /> �IFOtiZa`P NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAQkA&32 AM OFF-- C3 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work descnbed 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 /> � IWO L'! Assessors <br /> WELL Location Gi � D�>%✓� Cross Street ;9A6 14l*KCity Zip $�,�Parcel# <br /> PROPER L / ,, / �/ <br /> Owner `Tl' Or !�//rt�-v� Address Zl>•�-jj LZC40.0 City 422a2W Zip 5lk Phone# <br /> C-57 Contractor gkW-y Address5'32I'F.YL / City Zip�TJ�I -Lic# OOT Phane# <br /> Consultant!Sub Cntr dress 7,1/7 K!JCity Ee.G.DJ✓'Lic# Phone# ✓6�6f C ya o <br /> Gd <br /> GIS Coordinates X Y ,Township Range Section <br /> WORK TO BE PERF <br /> )(NEW WELL ORI (CPT GEOPROBE,HY ROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> SOIL BO G#_ P`�O # �I []OVER-BORE DIAMETER <br /> ,DWELL# 1]PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTIONSPECIFICATIONS <br /> []MONITORING Q HOLLOW STEM DIA OF BOREHOLE / O MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA <br /> []EXTRACTION 1]AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING []STEEL []PVC []OTHER <br /> . n VAPOR []MUD ROTARY DEPTH OF GROUT SEAL /s" TREMIE TYPE TO BE USED I]AUGERS HOSE <br /> q AIR SPARGE/OZONE *USH POINT(GP or CPT)GROUT SEAL PUMPED )^!es p No (NOTE- MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING []HAND AUGER GROUT SPECIFICATIONS /XlT C�l�lG►'y� <br /> OTHER OTHER APPROX BORING DEPTH Z-I— [I BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED_ d (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 9nd Regulations, and all applicable California State Laws <br /> Signed x / TitlelCompany A 641 / iC d ACa <br /> Print Name ` G//�� �i�J/�✓'`,S Date.,.,_ 001���y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS:_ f� 40, <br /> WORK PLAN DATED' 0-15 :22.2! <br /> Q �[ <br /> Application Accepted By Date Issued `" ^a \ Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS <br /> ACCOUNTING ONLY AID# FAG# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> n %a 7- Z. SR# D X27 <br /> C-57 WC -WAIVER C-57 letter of Authorization to sign permit Encroachment <br /> /d�occ <br /> EHD 29-02-001 <br /> 9/30/2003 VVV <br />