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San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> 209 468-3449 Pax: 209 468-3433 Web: www.co.san-joaquin.ca.us/ehd UNIT IV <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 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 /> Assessors <br /> WELL Location 13q30 1,c!U P 5ALRANfrV70 Cross Street 14ARVEV City L-00I Zip y5;tf�- Parcel# 60;$-07-00C <br /> P0411 <br /> PROPERTY <br /> owner f{EWrV AtS 4 Address POBOY 5757 City 1,011 _Zip7 1q/ Phone#.204- 361'6705 <br /> C-57 Contractor gfSOMNT SOA)je Address220 tLJ, CA 67. 677AFE'7 CitywaoVI1Wip157XLic#I02339Phone# <br /> t u7jF fA.)t71aAAf?- <br /> Consultant/ <br /> -Consultant/Sub Cntr E"A)S60 1A^ Address.2010 A 79A4!,r Vj, 10.3 City��Lic# Phone#109-S 35 •0616 <br /> GIS Coordinates:X 002 Y 121,-;665 tv .Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> SOIL BORING# 3 u 0 OVER-BORE. DIAMETER <br /> WELL# Q PRESSURE GROUT <br /> (]'Other GROUT SPECIFICATIONS <br /> COMMENTS: - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS o MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC a OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL ZS ) TREMIE TYPE TO BE USED: Q AUGERS U HOSE <br /> AIR SPARGE/OZONE I PUSH POIN (GP r CPT)GROUT SEAL PUMPED: a Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: a OTHER APPROX.BORING DEPTH 5 BOLTED TRAFFIC BOX or Il STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 6I AT- C f---Me ))—F ^ f--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,Rules and Regulations, and all applicable California State Laws. <br /> Signed x (/�, �! Title/Company ROS Cw7 OIW 7 f OWell <br /> l� <br /> Print Name CASEY GEE 7EeVSEN Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ` 3 6 rILZ <br /> WORK PLAN DATED: S v <br /> Application Accepted By L/l �-- Date Issued 15-16 0,7 Area 6 / <br /> Grout Inspection By I�t�tnwQ Date 0 Final Inspection By Date Cd e <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FACC70UNTING ONLY: AID# FAC# <br /> ES FEEINFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ��► do root: 5 6 0`� SRO <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> LHD 29-02-001 <br /> 9,30%2002 <br />