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` SAN JOAQUINCOUNTY FILE COPY <br /> y( ENVIKONMENTAL HEALTH DEPARTMEN F SITE <br /> Ir r� 600 East Main Street, Stockton , CA 95202-3029 MITIGATION <br /> ° 44e: (209) 468-3449 Fax: (209) 468-3433 Web: www . sjgoy.orglehd <br /> UNIT IV <br /> EB 1 7 2009 WELL PERMIT APPLICATION <br /> ENVIRONMENT HEAL-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> nE <br /> 4pplicatlon Is hereby mkjbVAFAut�€ 1in County for a permit to construct and/or install the work described. This application is made in compllanc_e with San <br /> Joaquin County Development Title, chapter 9A 115.3 and the Standards of San Joaquin County Environmental Health Department, <br /> Assessor's <br /> Nell Location 2575 Cdv a,-� Club Brrd Cross StreetI? rn OU44A Road City S,h e.k-fon Zip -9 ,3 2.9y Parcel # 123- 020 - 12 <br /> Property <br /> owner _ Day lei - oover Address E87 YAnq[in_ Vallip ennd City IA Invf r < Zip '?LI596 Phone # _NIA- <br /> C-67 Contractor Grcn 'D�1 \\i „� Address q 60 I-(-nwe. Rcacl City A40,r4iytv, z Lic # 94553 Phone- qz5 - 313 - 5800 <br /> ConsultantfSub Cntr n¢$oaa-VR vnrndll'�Addess 5900 Wlis Spree% S ' Ci �__ yy��,, �/,, yyt, /�/e � a+a 99too8 zr7 - 3 7L <br /> -1 yip' C City Phone - 5 /O - y 3 <br /> GIS Coordinates: X 3 1. Y ^ILt . �j �j r? Township Range Section <br /> WORK TO BE PERFORMED: <br /> 19 NEW <br /> )ME.LLJBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') - [I DESTRUCTION (CHOOSE TYPE BELOW) <br /> l Ig."j SOIL BORING# ❑ OVER-BORE DIAMETER <br /> [] *OTHER / <br /> El PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS:� _ s/ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING KHOLLOWSTEM DIA, OF BOREHOLE ❑ MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br /> 0 EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS -,- " TYPE OF CASING: ❑ STEEL _ PVC 0 OTHER <br /> 0 VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL ti THEME TYPE TO BE USED AUGERS 0 HOSE <br /> ❑ AIR SPARGE/OZONE 0 PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: 0 Yes W No (NOTE: MAXIMUM FREE-FALL DEPTH IS 307) <br /> SOIL BORING I] HAND AUGER GROUT SPECIFICATION-c 'Por � 4t-..d T[Uz Celt + <br /> t <br /> u,OYHER: ❑ OTHER: APPROX. BORING DEPTH ..vim {� BOLTED TRAFFIC BOX OR [ISTOVE PIPE <br /> -- . ,r- <br /> COMMENTSCONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> : rt� - <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br /> Regulations sand all applicable California Laws. - - <br /> Signed �Z� Ll4zz� Title/Company Qxww5/ Aa 37/0a 0, 10%6vtiis 14Sso Netyed <br /> Print Name 15klM 9EIAINfI4T Date 2111 /n9 <br /> DEPARTMENT USE ONLY GOi� <br /> SITE MAP IN UNIT IV FILE, ADDRESS: - <br /> WORK PLAN DATED: Z - cnp O <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS : <br /> ACCOUNTING ONLY: AID # FAC # _ <br /> PE CODES FEE INF AMT REMITTED _ CHECK # RECV'D BY DATE "PERMITISERVICE # INVOICE <br /> SR# <br /> C-57 V WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2D-01 1115107 (WEB) FILE COPY L PERMIT APP <br />