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San Joaquin County <br /> EP 1 2 200?Env ri onmental Health Department SITE <br /> C ` Mt Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> RM T ONME 449 Fax: (209)468-3433 Web: www.sjgov.org/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 /> �• Assessors <br /> WELL Location `1°I ` Q Cross Street sktj—city 1.10'm zipParcel# �Jr��©gO Z Z <br /> PROPERTY Q I �� <br /> Owner J_c��r� Address S 1r JYt rtp— City '.-n_ p M 3`iPhone#(Z.�113U���� <br /> C-57 Contractor iQ 5 TD1,111115 Address ��s t D City! `�"�Zip Lic#�Z <br /> 33 Phone# �z7 <br /> Consultant/Sub Cntr gQ<<x f-_"1Dkb jLw Address III,-AL1 F r lle-Wa ity 60jj j%Y4rLic# 4 6(01 8) Phone# M I U <br /> GIS Coordinates:X 3;1•73'Zk f("2 ,Y -&L 3`161 z 7 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# VP-1 y P-L�f P-3�YP-`I,V P-SvP-(,��((�•��Yt-8�V(�-`1 a OVER-BORE. DIAMETER <br /> WELL# P_�� 0 PRESSURE GROUT <br /> 'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: 1 <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL S CceJ- TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 1 <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') / <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 1.rw R <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH S r..t- 0 BOLTED TRAFFIC BOX or 0 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 /> 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 /> Signedx� ��� Title/Company SJ'f}R- ilw nNkuk To_( <br /> Print NameX�v�c r I t.raty� —Date— <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By �tid✓��S��-r` Date Issued A� Z 9 l/ Area 7 S� <br /> Grout Inspection By ff/j'/ Date o/g // D O final Inspection By A1641 Date ///o 7 O <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 /> q`f 3g CNy"p� l/ a] SR# (205,r••47 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/30/2003 <br />