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011/ [1/zt:iuo 14 Cil ZQj4bUJ4JJ FIFTH FLOOR PAGE 04 <br /> gLkIly O [E I �' i n Joaquin County f-)`) F <br /> D <br /> EnAranmental Health Department <br /> 4 fi,03104-Eastn"er Avenue, 3rd Floor,Stockt6n,CA 95202 MITIGATION <br /> Vt58-34.49 Fax (209)46$-3433 Web www sjgov org/ehd UNIT IV <br /> �f Permit Application ! G <br /> NON-REFt1NDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquln County for a permit t+v constructandfor install the work descrtbcd Thls application ie 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 A7.L C.---6 f 14 F31vJ Cross Street JeydP A v2 City f(0cP'i;>v+ Zip $520y Parcel# <br /> PROPERTY <br /> owner +-t( Address n`� ga �1 I Cdy Ck 45 Zip7 5'z=t Phone# <br /> G 5l Gonir&ctor U�tr� [,1��w�' AddressL475__Cc{r,40sr44 aCrtysl 1�F.11 7�p"/167& LI c4 Yoh Phone# Sb —4 2-T +i <br /> et— I xc�0oYa[a <br /> onsulta /SobCnir� ►��+t}En+� 'a,­0 Adds,, o�a,c etc QtyGe:dau-� Llc# Phone#',rb kw— <br /> GIS Coordinates X Y Township- Range Section <br /> WORK TO BE PERFORMED <br /> tI NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER OTHER-) ❑DESTRUC-PION (choose type below) <br /> a SOIL BORING# p OVER-BORE DIAMETER <br /> a WELL# 17 PRESSURE GROUT <br /> a"Othor GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALL TION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING p HOLLOW STEM DIA OF BOREHOLE=Z_jL" a MULTIPLE CASINGS o MULTI-LEVEL WELL CASING DIA _ W_ <br /> !3 EXTRACTION a AIR I-IAMMERIDRIVEN CASING THICKNESS TYPE CF CASING 0 STEEL (I PVC D OTHER <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /r0' _ _ TREMIE TYPE TO RE=USED p AUGERS a HOSE <br /> R SPARGE?OZONE(XPUSH POINT(GP or CPT)GROOT SEAL PUMPED gYas (j No (NOTE- MAXIMUM FREE-FALL DEPTH IS 30') <br /> •! OIL BORT Q HAND AUGER GROUT SPECIFICATIONS /Ij e,-.t _ C e:P_ R_ <br /> t 11 OTHER _ ^Q OTHER APPROX BORING DEPTH I r 0 � - p E0LTEO TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED—o _(if YES list specifications in comment Section) <br /> COMMENTS _ _- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOVICE 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 Ordinances, Rules and Regulations, and all applicable California State Laws <br /> S nedx Title/Company 5 `� 6?'& agY <br /> Print Name '3>&U,2, :BrT6c. ,, _ _--- 0atc <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN KNIT IV FILE, ADDRESS: ' <br /> WORK PLAN DATED' b <br /> AppWation Accepted By Date Issued 3— P-- Area <br /> Grout Inspection By Dace _ _Final Inspection By Dale <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS <br /> ACCOUNTING ONLY AID# PAC# <br /> " <br /> CODES PEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> i1yol , l�r6R �t SR# '06 ` 1 (01 <br /> C-57 7 WC-WAIVER C-57 Letter of Authorization to sign per'rnit_-_Enoronchr>Zent doc,_,�, <br /> EHD 29-02-041 <br /> 6!Z O4 <br />