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i� <br /> N ,LL PERMIT APPLICATION FORM <br /> hL' SITE <br /> SAN JOAQUIN COUNTY <br /> i ' ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> 04 MAR — 9 Ph Ioe41* E. Weber, Third Floor, Stockton , CA. , 95202 UNIT IW <br /> (209) 468-3449 <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 <br /> _9-1115.3 and the Standards ofSan Joaquin County Environmental Health Depart/m�ent. _ <br /> WELL Location _ IgUI �, ( T)()Icc tU Cross Street U4 i `1T City sjjy(k-t�g__Zip i zParcel# rs / �� —�(��—�C/ <br /> PROPERTY SQ �{�1tJ�Awn r— ictitiji rC 011 L j Poe do q sZc) c o l <br /> Owner -�FYl0..{11 Address vi� 0 l,Vy City W Zip Phone#�, +' <br /> C-57 Contractor Address i0iii 1E A,107'u W City fntkVA Zip 1b Lic# W Z&I ( Phone# RI 9o - �JS dJ <br /> Consultant / Sub Cntr ri G. � Address 951 1tWM) _.City r�'B�1LLic# b D 0?Phone# <br /> GIS Coordinates: X., Y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> T1EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER•) 0 DESTRUCTION (choose type below) <br /> a SOIL BORING # a OVER-BORE. DIAMETER <br /> ELL # LI a PRESSURE GROUT <br /> p Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> PQMONITORING HOLLOW STEM - DIA. OF BOREHOLE.JLS p MULTIPLE CASINGS 0 MULTI-LEVELLWELL CASING DIA: Z <br /> / <br /> B EXTRACTION - p AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL f,D`PVC p OTHER: <br /> U VAPOR a MUD ROTARY DEPTH OF GROUT SEAL LS TREMIE TYPE TO BE USED: AUGERS p HOSE <br /> a AIR SPARGE/ OZONE Q PUSH POINT (GP or CPT) GROUT SEAL PUMPED: p Yes 0 No (NOTE : MAXIMUM FREE-FALL DEPTH IS 30') <br /> BSOIL BORING aHAND AUGER GROUT SPECIFICATIONS per} ignJ cewr. evdF <br /> n OTHER: B OTHER APPROX. BORING DEPTH L-I C.5 r ,BOLTED 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 /> 1 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 /> Signed x�l CqM(�_ .aA��t�' p Title/Company [64l L !'t �� <br /> Print Name 1jin.1 'TeAA-t.. L.. - tti5tn'Q.� Date v4 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED ' p <br /> Application Accepted By l_ . ._ 1. r Date Issued / .wArea 4 <br /> Grout Inspection By Vi Date Final Inspection By j ,.V1G 1 - Ll Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS:. <br /> / <br /> ACCOUNTING ONLY: AID# FAnCC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # RE6'D BY DATE PERMIT I SERVICE REQUEES.T # INVOICE <br /> C-57 WC.-WAIVER. C-57 Letter of Authorizai sign permit_ Encroachment doc_ 9/30/02 <br /> i, <br />