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� V <br /> San Joaquin County n <br /> -Py <br /> _ Environmental Health DepartnTAtlnGgf4,-gji.i KA [I SITE <br /> • `° 304 East Weber Avenue, 3rd Floor, Stockton, CA 9521 Ilkl 'I T ' ER,AD- ITIGATION <br /> (209) 468-3449 Fax (209) 468-3433 Web www sjgovOor�ehd 2 � } UNIT IV <br /> �P 's <br /> 4L FO � <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS ED 2.. <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 /> /70 <br /> WELL Location 6 G Cross Street City Zip f33)10 Parcel <br /> PROPERTY <br /> wnnera,C Z&P /T �GT ddress Z" C/1�'�"PWQX City Zip y"t���s�O Phone# C <br /> C-57 ContractorLc��lt/�1s'yO j41k4oWAMdress ✓�V �✓��/L- 4l7 City�d s iP_!'�LLic# �/�/Ph°^e# 7�p/�y— ���70 <br /> Consultant I Sub Cntr ,a05.110� Address/1 fuWOW AV City g5! ic# Phone#wow <br /> GIS Coordinates X ,Y ,Township Range Section <br /> WORK TO BE PERFO <br /> NEW WELL! NG (CPT,G PROBE,HY OPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> []SOIL BOR -/Z L3 ��� 4 OVER-BORE DIAMETER <br /> WELL# a PRESSURE GROUT <br /> Q <br /> a`Other GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA OF BOREHOLE Q MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA <br /> 0 EXTRACTION AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING 0 STEEL []PVC a OTHER <br /> �a VAPOR []MUD ROTARY DEPTH OF GROUT SEAL Z4E TREMIE TYPE TO BE USED D AUGERS []HOSE <br /> []AIR SPARGE!OZONE RUSH POINT(GP or CPT)GROUT SEAL PUMPED , Yes p No (NOTE MAXIMUM FREE-FALL DEPTH IS 301) <br /> xOIL BORING HAND AUGER GROUT SPECIFICATIONS 14afr­ C T <br /> []OTHER fl OTHER APPROX BORING QEPTH �f a BOLTED TRAFFIC BOX or ()STOVE PIPE <br /> CONDUCTOR CASING PROPOSED P (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 l have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinanc , RUI 0sand Regulations,and all applicable California State Laws <br /> /� Title/Company �'rr � , <br /> Signed x e� <br /> 01 <br /> Prirt Name GG�Nr _ Date <br /> DEPAR <br /> T�//TMENT USE ONLY <br /> SITE MAP IN UNIT N FILE, ADDRESS: le f/� — <br /> WORK PLAN DATED' J45110g 7 Q <br /> Application Accepted By <br /> Date issued ` V • � Area <br /> Grout Inspection By _Date_________---Final Inspection By Data <br /> Destruction Inspection By Date <br /> COMMENTS ICON DITIONS <br /> ACCOUNTING ONLY AID# FAG# <br /> iPE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> G57 WCC[-WAIVER C-57 Letter of Authorization to sign permit— Enc meat doc „C <br /> ESD 29-02-001 <br /> 9/30/2003 <br />