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pian Joaquin County slm� <br /> nmental Health Department SITE <br /> F <br /> CE��47ber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> �4�ti oRt',P SEP 1 2 2007 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is ereb� tl¢ gjt for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joa uin CountyDevelo 115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location `S `1 Cl I P S p Cross Street City Zip 5 5: 1]L Parcel# <br /> T- <br /> PROPERTY exn I Zi 3( e Z, 1) - 8 S -a� 5 <br /> Owner �St�( �rC _ Address S� 1 �F/ 5�Yi'� City / O� / p /9S?^J `lPhon / <br /> C-57 Contractor �S� /��.���'1 Address /� t 0kkU Zip 9577�Lic#�Z334Phone#q 3� 2 Z`1 <br /> Consultant/Sub Cntr�Q(y��C t L,,CM r}Z rir,tAddress 1 (",y PYf t1e�Wu ity Goll��Yt►'Lic# to Phone# 1 �l ��� � <br /> GIS Coordinates:Xi 7.,7 r2 9( Y- Z(. 3 7 3 7-7 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER') p DESTRUCTION (choose type below) <br /> SOIL BORING#-VP-Oj �/ I r_YP-13 aOVER-BORE. DIAMETER <br /> WELL# a PRESSURE GROUT <br /> 'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING a HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA- <br /> -0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL 0 PVC a OTHER: <br /> p VAPOR MUD ROTARY DEPTH OF GROUT SEALS <br /> f,-1- TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> p AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: G Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS L <br /> p <br /> OTHER:_G OTHER APPROX.BORING DEPTH 5 f"v a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (f 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/Company $jet'-.t- (Ge CX G' (Nyi rV k(.R SA-(- <br /> Print <br /> a.0Print Name XIV Zc n'^' Date �Y U <br /> T <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By ci'/:;2 Date Issued lG/9l6' Area <br /> Grout Inspection By Date/19/X/ //p inal Inspection By �LILl� Date 1447 d7 <br /> Destruction inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3`'°�35u3 g9 29 �3 "3L91Z �O SR# 4OS21-130 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc P�d<i ''1CS <br /> ERD 29-02-001 D7- 2i:3-$W <br /> 9/30/2003 <br />