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San Joaquin County <br /> EnVi-onmental Health Department SITE <br /> Awl ,(� Of fit Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> ''v l0 )468-3449 Fax: (209)468-3433 Web: www.sigov.org/ehd <br /> U T IV <br /> ENV <br /> D9R' i1T/ CEI �CEMell Permit Application FIL-Utfur <br /> °E�sP�11TJS�RVICES <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 �� -C - 4­xoz Cross Street r�v£�il� Cit )�ac �T�Ji Assessors ►C�i/ <br /> y Zip�j s21, Parcel# DaC-� <br /> PROPERTY <br /> Owner Lei. e Scw� .viM1O�� Address `Q' CLeroko' City560— ZiP9>-Ii Phone# ,j <br /> C-57 Contractor �n+,� r; ttvrrIj �r4 Address �5� C �E'r 1 `� �+ } ?<- <br /> e jj c City(\�� Ys c Zip��� �Lic#�Ij%'`�'c/Phone# �C-�"3Tf'"�Cr' <br /> Consultant/Sub Cntr 4TC, ,;,,,-7r{ Address I i1� 4- t'-,(- Zee Pt,;,;�' . <br /> 3 -city ,.c Lic# Phone# A1-i-� -5-2Z2( <br /> GIs Coordinates:X Y �~ <br /> Township fy Range Section 1 <br /> WORK TO BE PERFORMED: <br /> ;)(NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# 1/ti.+ar> , Wp j( 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS:` (\ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING XHOLLOW STEM DIA. OF BOREHOLE=' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: � lr <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5C ) TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1-5 TREMIE TYPE TO BE USED: `AUGERS 0 HOSE fi <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 'Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 ) Q <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH lot )(IBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED f"4C7 (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 /> 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 /> Signed x Title/Cc:n am <br /> P , JAI as SU !a t cS t c <br /> Print Name E DateCETT cj <br /> I DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS:__6 732- <br /> WORK <br /> '32- <br /> WORK PLAN DATED: / <br /> Application Accepted By LA�nt t�1 Date Issued 6 € n, jZp Area <br /> Grout Inspection By �it;� ld Y77,& r Date L-19-n j_Final Inspection By Y LA{,'a."bl Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: &F y W S <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3s°j `joy. oo 0'J6Zs� b o1 SR# :�Ss Z <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 />