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WEi.! PERMIT APPLICATION%.,4RM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) �s((,; IJ <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 MAR 12 2003 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A� LTh <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applic.A.Wi�WR�with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health DepaR � <br /> WELL Location 530 E. Market Cross StreetCaliforni Assessor's <br /> amity Stockton Zip95202 Parcel#(_1149-130-18 <br /> PROPERTY Owner The Record AddressP.O. BOX 900 CityStOCktOnZ5201 Ph 2#9) <br /> C-57 ContractorFisch Env. Address399 Sheris P1. Ciryal �i 9ip!_ 525Oc#68386Ghone#(209) <br /> Consultant/Sub ContractorGround Zero AddressI.714 Main St. CitiEscalonLic4023 Phone# 772-3570 <br /> (S2q.9) 838-9888 <br /> GIS Coordinates:X Y Township_ I N Range_ `E ec on_ <br /> WORK TO BE PERFORMED: <br /> XI[NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> X j&SOIL BORING# 1 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications:Ne at <br /> COMMENTS: Borings to 25 ' depth <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2° MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE XI[PUSH POINT GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> {SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 2 5 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR ASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: 1'�A r r Y\A c ConnC214rAe G re)t&�a'�RX- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinance , Rules and Regulations, and all applicable California <br /> /State Laws. pp�� <br /> Signed xs— 4, _Title/CompanZEyo <br /> Print Name Jo�,v\. ('"ck^,e-- Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: - 3a MaAkt-* <br /> WORK PLAN DATED: x <br /> Application Accepted By Date Issued 3 1 l I b Area 17�y <br /> Grout Inspection By U Date 3 Z$ O 3P Final Inspection By tL4AAAe," Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 5o f a- 3 t3 33 0 5 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br /> �1LE C�P`l <br />