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Ilk <br /> : a '={ San-Joaquin County - n <br /> 'w.r:<:,,,° Environmental Health Department U <br /> •+1.: ;•;rd`s .....w�..,. - <br /> v <br /> 304 East Weber Avenue,-3rd Floor, Stockton, CA 95202 MITIGATION <br /> v: :=> "s': Fax: (209)46$-3433 Web;www.sjgov.orglehd S�P 3 <br /> 0 ,121191-468-3449 <br /> 2QVIT IV <br /> h �n <br /> Welf Permit Applica#ion ENVJRofVIU����1-r�t rN <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YE;4R'FROM DATE ISSUED ���I.Vr� ISEVICES <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicatsan is made in compliance with San <br /> Joaquin County Development Title,Chapter 8-1115.3 and the Standards of San Joaquin County Environmental Health Department- <br /> Assessors <br /> WELL Location'.73,>6- Cha:rrreI St'-rel` Cross Street ff &�^arrf City 5tocktor+ Zip_1?r-_7-Z_ Parcel# !S7-2'7ey�y'� <br /> PROPEPTY <br /> Owner Address `�17 s- CC.Aa f ty- City SIM-1<14� ZipffZZ (- Phone#(:Z&O cf.b -&-OV <br /> -C-57Contractor Address /L-A-- r6-,v.r City:EJ�etf,-i Zip9*)(/ Lic#2o90( Phone#(9'145--7-P2- <br /> /.1515 tm..k were-ca.0 c <br /> Consultant/Sub Cntr Cori-foY Address Jc-v1_G -P- City;Ybc+-cOb"Lic# Phone#t'9&q)-2T9'-J8 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL! BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,-OTHER•) p DESTRUCTION (choose type below) <br /> a SOIL BORING# 0 OVER-BORE. DIAMETER <br /> )(WELL#_3 - ©PRESSURE GROUT <br /> p Other GROUT SPECIFICATIONS <br /> COMMENTS: f!vb��t�� r�or/c�1uc�%I:-,ed. ✓l�h:_h,-,rte Gf ellaL'��1x2/af7 LJ..ss 4--r �o.l� 2y,/r1��1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,MONITORING tHOLLOW STEM DIA:OF BOREHOLE �" [1 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: -7 <br /> p EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESSski Y TYPE OF CASING:' 0 STEEL ffPVC p OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL 3o TREMIE TYPE TO BE USED: ,9 AUGERS ©HOSE <br /> p AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ((Yes d No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> Q SOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS_ /e..r C_e,,,, <br /> 0 OTHER: li OTHER APPROX.BORING DEPTH 5-(> §%OLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 O;dices ules and Regulations, and all applicable California State Laws. / <br /> Signed x. Title/Company W C:r✓re C,-e.,4,,riy r�a <br /> Print Name 4 e,2: "MCI)-J- Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: '230 EgL5+ C k a nor e l Sfye c f , S±QejC+n-n . e_A <br /> WORK PLAN DATED: 1 .2o64 <br /> Application Accepted By Y i G+o y i n L. Mr. Ca V+n e y Date issued S4ep ft <br /> B?ri6 j&ir )t a404 Area_ <br /> Grout Inspection By V!eiar i eML Date 5- :24 04 Final Inspection By c,CYje,.._Me4d��ate <br /> Destruction Inspection By Date <br /> COMMENTS 1'CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 35 01 �q,0o 8 4.oD SR#- 00 39 G 0 ! <br /> 457` WC -WAIVER- 457 Letter of Authorization to Sign permit^e=ncroachment dor <br /> EHD 29-02-001 <br /> 6122104 <br />