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j�y M i kfe �n�rna. <br /> San Joaquin Co�trFEI -, <br /> Environmental Health Departmenn SITE <br /> ' < 304 East Weber Avenue, 3rd Floor, Stockton, CA 9 0 " ' LO.b MITIGATION <br /> (209)4683449 Fax: (209)468-3433 Web: wwW.sj*NWVAlW1EN 1 HEALTH UNIT IV <br /> a `P. - PERP!1IIT/SERVICES <br /> vFOR Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> the wok described. This <br /> JoaquinlCo my De elopment Title,IChapte C9-11 5.3randpermit <br /> Applicaton is hereby made tSanheStanda ds of Sao Joaquin CountyrEnnvironmental Health IDepartmentade in compliance with San <br /> �/l n A// / II-- '}' Assessors <br /> WELL Location—HanSIe_nI Kia Cross Streei . OfS n ity I�ZiP n Parcel# <br /> OwnerE(n��PY1 ) 'ic 0.����OAdtlress l3_�QI���e ��yCity N! 4 (�ip QJ7Y5p4[6 Phone# 1�5 � !-7I �4 <br /> C-57 ContractorTe5N RmPri(a Address 1016 EI?St W LP �Ct_.city Zlp_g12jLic#8t4J SPhone# t't-qC D <br /> Consultant/Sub Cntr 5 1 �- Address 000 ( S 6CIry5 (glklcn�Lic# Phone# 5 to wa 716 <br /> GIS Coordinates:X <br /> y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 00 o ER-BOCTIRE. N (choose type below) <br /> U SOIL BORING# <br /> WELL# 0 PRESSURE GROUT <br /> .*Other C(?T GROUT SPECIFICATIONS <br /> COMMENTS: ' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SP�]ECI1O MULTIPLE CASIIFICATIONS <br /> INGS Q MULTI-LEVEL WELL CASING DIA: <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLES <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL PVC I]OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> a AIR SPARGE/OZONE '%PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> `,SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> Il OTHER: a OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or 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 hA' ules ave prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi cand Regulations, and all applicable California State Laws. <br /> Signed x Title/Company � <br /> Mt�. 0.-P i Date 6'�'L�/ <br /> Print Name Nuri - <br /> DEPARTMENT USE ONLY <br /> .� �9 d <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: / <br /> Application Accepted By <br /> Date Issued rIM Area O� <br /> Date Final Inspection <br /> Grout Inspection By lid <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> /Wo ? SR# O© b <br /> i <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment docit <br /> EHD 29-02-001 <br /> 6/22/04 <br />