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IrJoaquin County <br /> • <br /> :a r �on <br /> iron Health Department SITE <br /> Q4 E eber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (208- 4 9 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> UNIT IV <br /> E(�vIROVPr Jam- HE,A' l PermApplication <br /> F/SER tl, C Permit App cation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> kpplication 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 /> t ^ 1 " Assessors- <br /> WELL <br /> ssessors-WELL Location Cross Stree � .1 City �Zipf� �V <br /> 1 Parcel#_ (3j2:2 001 <br /> PROPE TY `' <br /> Owner M=(' SPcA LA__ Address "I��� 1�� .�,1�. City Jd���- Zip ZOC Phone# - 'D q-Z'7>" SIK-1 0 <br /> C-57 Contractor-I t 7-r -, Address3$�3-C. Zip'jD S Lic# Phone# 6-(4) 3 -1 ZZXz, <br /> Consultant/Sub CntrZ I Z 1 14 , !G g - <br /> �S C.'-" Address-�� .4 c 4 Z a City_CLic#F�3Phone# k 7 %)1 g't-(66'_-> <br /> 1 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW`414EL ; DO • , <br /> u L FvltdG (CPT,GEUFRGBE, HYDitOrUNCH, HAND-AUu^Eri,JTFiEK`) p DESTRUCT ION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> -WELL# Z 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA. OF BOREHOLE SZ" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ? " TYPE OF CASING: 0 STEEL XVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: �G Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS-f�,__ '-1c_ <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 12BOLTED TRAFFIC BOX. or 0 STOVE PIPE <br /> // CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: b�3� W• o <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, Ruled Regulations, and all applicable California State Laws. <br /> �— --- <br /> SignedTitle/Company <br /> `=� ^•�-� ---- <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: CU C-C3 JX-A-L <br /> Application Accepted By J Date Issued l—�I 0 Area 99 l <br /> Grout Inspection By Date/0/ (S Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 6&kS M cUS (2 P o SY K•� SfK rLSu µit <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> r SR# boil a <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />