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"Joaqui>h County FILE COPY <br /> ,o.•q"•I`�••.�o �� `•_,. ^in�,,n;�r � <br /> Environmental Health Department SITE <br /> IJAtI4-Fast? er Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> „ <br /> )9.),468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> WELL Location A7X5'-C -6-y t lwj PlItIzA Cross Street i�yclP Ave City Zip X52'. Parcel# /ZI '2t -00G <br /> PROPERTY <br /> Owners-t( -J Address P-''•FSV)r Z I I City-Dk1►as Zip7f ZZt Phone# <br /> C-57Contractor (mit'!jg 3):*'tl: AddressRH7S- Cer(�I,-s,4,3e CitySi^k14-11 Zip 5��'''V& Lic#t)S'by07Phone# SbL-`{27 68�j <br /> Ituc I-0 <br /> ns <br /> oultan /SubCntrs�'��In}e7x�}'.a.�.Ll Address '300 K;I�a,ie 2-A ncityCo;•Acoe'. Lic# Phone#9O"fT61-0`/00 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# f /I 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE2IE! a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /eO l TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 'R SPARGE/.OZONE X-PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> �001E BORT � 0 HAND AUGER GROUT SPECIFICATIONS JUS et t" C e�--e^t <br /> D OTHER:_0 OTHER APPROX.BORING DEPTH 00 ' 0 BOLTED TRAFFIC BOX or 0 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 /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x ^�' Title/Company s'-a. 67 ey X04 rr 1 - �7 L��2 T„)J. <br /> Print Name 3�'4-U40r 33 rocs-)Zt Date 2- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: Z a <br /> Application Accepted By Date Issued /^Z I—�S Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> --CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 / <br /> 6/22/04 <br />