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'*—San Joaquin County IR IE�'�`1 (' \'j' <br /> Environmental Health Departmen `� V SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton, CA 95202;;, 2� �, r <br /> • ,;:.,,� .6 � L�UB MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.org/ehd <br /> UNIT IV <br /> 0llllel! Permit Application ENVII 0f\-,110E€�i"i 11EALT'' <br /> . >]��'Z11lii i���i'�iL/ILLt3 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County fora permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-11i 15.3 and the Standards <br /> (ofytl,,San Joaquin County Environmental Health Department. <br /> WELL Location i 1116 5. � wr"11✓( S+' Cross Street wool-; Ulu S�OG�c kwl L15� <br /> Assessors/b5­03 <br /> /�5 07(}— 1(] <br /> �1 City Zip Parcel# ! <br /> ; <br /> PROPERTY,^ �� 4/171; <br /> j z <br /> Owner_ it;'VID� 4 �VAL4 Address I.3� SCu'7V, Pew, Jr/171; 1City Zip l5 j Phone# <br /> // �J f� .J <br /> C-57 Contractor_65(fiiir° UFlIlr'') �, Addresa-5LZ(�r3iJl 61r.b Al <br /> f1 cityam k(z'66'Zpc(52y-?uc#71757 Phone# �/"J5-/bbl <br /> Consultant/SubCntr�1-�LtU'S t1Vi!L' � sL j���,Address"5L `r' fy) /'G (1/l,Ir51City �y �' L, St'''Y� Phone#:�.3o-0A,-aCs�Z <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO gg <br /> PERFORMED— <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") Q DESTRUCTION (choose type below) <br /> Q SOIL BORING# Q OVER-BORE. DIAMETER <br /> LL# 5-Z, ;V':^J.(, Q PRESSURE GROUT <br /> DIAMETER- <br /> Mother " GROUT SPECIFICATIONS <br /> COMMENTS: r1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICAT4CWS rJ 6110'' <br /> �10NITORING �S-iOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING <br /> WEXTRACTION Q AIR HAMMIER/DRIVEN CASING THICKNESZ LIL) TYPE OF CASING: Q STEEL VVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL Vl1/a01� TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> -XAIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes <br /> , Q No (NOTE- MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING � <br /> Q HAND AUGER GROUT SPECIFICATIONS r1ea, (.�JW <br /> Q OTHER:_ D OTHER APPROX.BORING DEPTH_VtVi-11 1-� '`BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> 9 r CON,Dy CTOR CASING PROPOSED (if YES/,list specifications incommentsection) <br /> COMMENTS: SC'� u°L�t(�( Ct l k5t hL9 Imo! (�4L� �7f7 ( t'iCU f Uy75 �/ f Sty ryT/t7j/Irl L!`t prl r4YX/) <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 /> S Ufl-" /' <br /> Signed x �n L Title/Company [f,Lk i S4 / S;'UG'.5 I�Ivi <br /> Print Name L -tUTt 151 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1 a S <br /> WORT( PLAN DATED:_ <br /> Application Accepted By Date issued ? a _Area <br /> Grout Inspection,By ! Date _Final Inspection By (e Date <br /> Destruction Inspection By Dat <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <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 />