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%ago, <br /> DWELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> OC 1 12 2004 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) TION <br /> UNIT AA <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> EiNVi 0i",lJENT HEALTH (209) 468-3449 <br /> Ptz t <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 2polication 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 /> Polly <br /> p 953 Assessors <br /> WELL Location 16 C. �iVF Liht �vt Cross Street Polly .o( City r te/ Zip 6 Parcel# 21'`35004 <br /> PROPERTY 1' <br /> Owner Lyp_ i Address 35 <br /> _064�V k; q S{� City � � � Phone# Slo- -43:2 -5' -c0 <br /> C-57 Contractor �rr{(� {Tt/,P, Address Y50 Zip04s53 Lic# SSI 5 Phone#iZS-313 <br /> -Strap <br /> Consultant/Sub Cntr_ ASsoGi-T�f Address /1I3 j, P P-J�& f4,9Cityh,4n Lic# Phone# ZC?9-54g-222I <br /> GIS Coordinates:X Y ,Township 1 z Range 5 F Section 16 P <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING CPT EOPROBE,HYDROPA AU 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# CPY GPT Z a OVER-BORE. <br /> RESSURE GROUT Q WELL# <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z~ MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS A/A TYPE OF CASING: 0 STEEL 0 PVC D.OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �S r TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONEVUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 17 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A/0 (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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinance , Rules <br /> Aand <br /> � Regulations, and all applicable California State Laws. <br /> Signed X _ll�•Jlz„r —.J�`" — Title/Company -,,,t \3 ��A_Jj <br /> Print Name ��� � Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: J Jr G ran f- Line- R04 a( Tr a GN CA <br /> WORK PLAN DATED: Apr; ( 1 R 200 4 and Addendum dcind <br /> Application Accepted B L G Date Issued 10- 13—o4 Area 4 S9 <br /> Grout Inspection By Date J Final Inspection By r/ D� <br /> Destruction Inspection By Date p <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 /> 3501 89.00 99, 00 sR# Oaf 8� <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_,Encroachment doc 9/30/02 <br />