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,a "'�•. a On Joaquin Cafltvtty O f 1 L E COPY <br /> 2 Environmental Health''Oepartment SITE <br /> e 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> (209) 468-3449 Fax: (209) 468-3433 Web: ww-,v.sjgov.org/ehd MITIGATION <br /> UNIT IV Fo�N Well Permit Application 1006 MAR _ p <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED S 4 Pr JQ �,.: rt��Q- I9 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. ,,rr U , �vi'"` <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environment�HePC/ 7�� C�Jrrkprltpliance wit an <br /> VISTA <br /> AL <br /> WELL Location 18y� EIbGb AUE410, Cross Street 841dA VISTA City STactr.TarJ Zip 203 par �l33 '5/" 'Z6 <br /> PROPEeRT—Y'1' �f \ C ./ <br /> OWner✓TKhTOAI AIT ��D—'%-rACT AddressZ2Aj W. Wff541U�(I�r TDA4 Zcity r.XKj;A( Zip�_Phone ZDq/ / 6-QZY jo <br /> C-57 Confractorg{_smgy Sm MIC Address 220 N. EAST ST City1„bl)gA�iA Zi�ST710 Lic# 2� <br /> _ 80 3'� Phone# d -zyzy <br /> Consultant/Sub Cntr_ ogTN Ifefl.l WC AddressJpr/S� �CIVF2 isq.kA City -SE. Li,# Phone# D� 2 1.2&O <br /> GIS Coordinales:Jl�] S? 3 ,y�1121°IQ.17 ,Township Ran e <br /> 9 Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CP , GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> I SOIL BORING# 5$�{7 <br /> DWELL# DOVER-BORE. DIAMETER <br /> 0*Other 0 PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <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: n STEEL n PVC n OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: n AUGERS n HOSE <br /> n AIR SPARGE/OZONE I PUSH POINT(GP or CPT)GROUT SEAL PUMPED: <br /> n Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1 SOIL BORING n HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH /S n BOLTED TRAFFIC BOX or 01STOVE PIPE <br /> COMMENTS: 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, d Regulations, and all applicable California State Laws. <br /> Signed -�f1s-. lJ,• Title/Company CrFiW4./CT��l�,7� <br /> Print Name AUL. Date_ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /PS6 d404 C <br /> WORK PLAN DATED:„ /— �/� OG <br /> Application Accepted By949� [�� <br /> Date Issued 3—a Q.� Area <br /> Grout Inspection By Date Final Inspection By Dale <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> bACCAID# FAC# <br /> AMOUNTREMITTED CHECK# REC'D BYEDATE. PERMIT/SERVICE REQUEST# INVOICE <br /> sR# <br /> C _ =WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />