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"'-&an Joaquin County FILE <br />CO • <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.co.san-jOaquin.ca.us/ehd UNIT IV <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 />WELL Location qJ W es+ lI 5 Toss Street __City Zip Parcel# 135130 <br />C57 Contractor M I C T -(I fAk Addressf,Ob)� Nlilnz?�11.1 City 4Uhkf&.6 pii& Lic# hone# 9/G &6 "3f- <br />ConsultantlSubCntr (r� Address 1�i% s(tiA...a � CityS'}OLIG' Lic# 4 $0 9d7 Phone#o2Q2%L -L_ <br />GIS Coordinates: X 'Y Township <br />WORK TO BE PERFORMED: <br />NEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # <br />-WELL# / <br />�) Other <br />Section <br />p DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE__7"0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 10 it <br />0 EXTRACTION 0 AIR HAMMER/ORIVEN CASING THICKNESS X 2 TYPE OF CASING: 0 STEEL)IfVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL__S Z TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes�Tlo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS O{t ao�'��1L <br />0 OTHER: 0 <br />APPROX. BORING <br />BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 Ordinances, Rules and Regula 'ons, and all applicable California State Laws.. <br />Signed xTitle/Company r i C31 GO i <br />Print Name DOywV\-o"_ 5 e_k Date <br />SITE MAP IN UNIT IV FILE, <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />COMMENTS I CONDITIONS: <br />DEPARTMENT USE ONLY <br />45 ;9W. n" %, T. <br />Inspection <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT/ SERVICE REQUEST # <br />INVOICE <br />o <br />g r70 <br />50 <br />-7-sR# &40V4�133 <br />C-57_ WC_ WAIVER_ C-57 Letter of Authorization to sign permit Encroachmennt/doc(��/`/n <br />EHD 29-02-00Ir/7- <br />9/302002 <br />