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I <br /> ' �- I�j�� �' FILE COPY <br /> CENQQ• San Joaquin Con �� �� <br /> ironmental Health Departmen ED SITE <br /> 1 0 [11 00 East Main Street, Stockton,CA 95202-3Oj&& 1 �U/� MITIGATION <br /> ' WEN f HEA4�6�8H3449 Fax: (209)468-3433 Web:wwwrsjgp,�ao�eA T UNIT IV �D <br /> RMIT/SERVICES Well Permit ApplicationCIVFVER(JIT/�E' tIErALT <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED �V ICLS <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&11,15.3 SnS(the Standards of San Joaquin County Environmental Health Department. <br /> o �e�d`u <br /> WELL Loeation,d/v. ��^��"�fyy9ttyKps�r �#Wtj�Cross Street �/er-f 5j. City Suck/o., Zip O2 Pareaw <br /> PROPERTY <br /> wner^ (fir <br /> Os `Y sY..4�e...j 9fior <ao 9�9vfr-789/ <br /> Wit City _ . Zip ?hone# . <br /> C-s7Contractor/,cec:s,a„ Sw�,/.ay Address 2?65 G�-gw4„ �c City ockfon Zip3:Zo67 Licl phone#(1o9)y6S-F7/2 <br /> Consultant/Sub Cntr Address City . Lic# Phone# <br /> Li t� <br /> GIS Coordinates:X 1 bl) ,Y Tovmship Range - Section <br /> WORK TO BE PERFO NI • (((6TTT <br /> g NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 46 g DESTRUCTION (choose type below) <br /> 0 SOIL BORING# I q _ •_-„e - ,� 0 VER-BORE. DIAMETER <br /> CM'"'�� I PRESSURE GROUT <br /> a-Other G OUT <br /> SPECIFICATIONS <br /> COMMENTS: OS-/-30Z601-9U. OS--.2 LOA6oLo,os-��o�9g OS-v-3o�Ni�o OS-S-?A Ao�96y a4,-D/t-�YD a4,asiy <br /> � -7 <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: g STEEL g PVC 0 OTHER: <br /> EA <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SL TREMIE TYPE TO BE USED: R AUGERS 0 HOSE <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 /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH <br /> • 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (N YES,list specifications In comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. C <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 i <br /> County Ordinances,Rules and Regulations,and all applicable California State Laws-' <br /> Signed /y rdlelcompamy SSG f S�-rcn>`rsf/Tie 5oc. e Godo`tic. ; <br /> Print Name fir/a. Date/f��00/0 <br /> DEPARTMENT USE ONLY.( <br /> Lo R 8 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 110 Al <br /> WORK PLAN DATED: 23 2010 <br /> Application Accepted By Date Issued Ali AreOfo C�7— <br /> Grout Inspection By Date Final Inspectl�nf :FMa <br /> Destruction Inspection By Date �JIO --j 7 6 <br /> COMMENTS I CONDITIONS: 4 it <br /> ACCOUNTING ONLY: AID# FAC# 3 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 35oy 6Q �p26 -j- g-►t-►o sR# D(oOZo3 <br /> C-57_ WC=WAIVER C-57 Letter of Authorisation to sign permit_Encroachment doc� <br /> Ela)29-02-001 WEB / <br /> 9/11/2007 <br /> FILE COPY <br />