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FILEPy <br /> CO <br /> an Joaquin County , <br /> ° ECM"Dnmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION,. <br /> NO(2090490TF49 Fax: (209)468-3433 Web: www.sigov.org/ehd UNIT IV <br /> L.; otz ENMRONMENT HEAL' 011 Permit Application <br /> PERMIYa4N FABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED D1 <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 <br /> Department.Assessorf <br /> CJS <br /> WELLt Lo�cAat n Cross Street �T- City&O� o . Zip 1 Parcel# <br /> PROPERTY c- n.� E (@0 ry5 r ,_ <br /> Owner � UF.�TOCKTb� Address_�� Ci Locl�� Zip�SZa�Phone�#��� p•-��i�u <br /> 'C-57 Contractor Address )�3� �'� Ci `�4 &m`*p����if �-hone# I� 6-953`G;D <br /> I if Consultant!Sub Cntr ` ► _.Address NtO [Gb Cityl�4�hrf-3� Z" Phone# <br /> , GIS Coordinates:K Y• Township Range Section <br /> i WORK TO BE PERFORMED: <br /> (NEW WELL/BORING. (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION {choose type below) <br /> �IL BORING# "' OVER-BORE. DIAMETER <br /> LL#_ A �x 0 PRESSURE GROUT <br /> 0"Other (.� J GROUT SPECIFICATIONS <br /> 4,01 W <br /> s COMMENTS: <br /> II. TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> E 0 MONITORING 0 HOLLOW STEM DIA:OF BOREHOLE /-5 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> {I EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC GOTHER:mm <br /> %VAPOR *PUSH <br /> MUD ROTARY DEPTH OF GROUT SEAL � TREMIE TYPE TO BE USED: Il AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE POINT(GP or CPT)GROUT SEAL.PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> RING HAND AUGER GROUT SPECIFICATIONS <br /> d <br /> solL Bo 0 <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH �"'t'�� n BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> eA <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 Ordinan�Rule an Regulations, and all applicable California State Laws. <br /> I <br /> Signedx- Title/Company <br /> ; Print Name _ Date <br /> DEPARTMENT"USE ONLY. <br /> { SITE MAP IN UNIT IV FILE,ADDRESS: 1� S C. y. o4 � <br /> WORK PLAN DATED: <br /> I - <br /> a Application"Accepted By _Date Issued Area v <br /> Grout Inspection B v11 Date Final Inspection By ' '' r to <br /> Destruction Inspection By Date <br /> [ COMMENTS l CONDITIONS: <br /> i <br /> ACCOUNTING ONLY: AID# FAC# " x <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D B DATE "PERMIT I SERVICE REQUEST# INVOICE <br /> sR# <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to Sign permit____,Encroachment doc <br /> EHL)29-02-001 <br /> 70 <br /> 35 <br /> 6122/04 " <br />