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O1 *an Joaquin County 0 <br /> i Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> c L Foaa 006 MAR 27 AM 1I:V&II Permit Application <br /> b A P: .i UirA y, LE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is herebyfffc prftq�yj C q Wobrity for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County DevelofPmeTc�Y T/i t@rT9N 11N.$and the Standards of San Joaquin County Environmental Health rDepartment, <br /> WELL Location 'f zl ') ¢L1�Q'[�l)� Cross Street �I'1� Qp City Zip "/53��Parcel#Assessors <br /> PROPS clwmi� q 7'' <br /> Owner �( Q �i °(F Address �a01 = 6T?-ELT Zip j Zl Phone# /((p, >r.-1� �W-� <br /> C-57 Contractor Address City Zi Phone# <br /> Consultant/Eeb-Ent�1� lL Address 40iib <br /> Lic#-SA�Y�� ✓ Cityr��}a,1, �Lic# Phone#'in�1 <br /> l(p. 1� <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) `dDESTRUCTION (choose type be ow) <br /> a SOIL BORING# //a OVER-BORE. DIAMETER G <br /> a WELL# a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: MW-/n I0AL)t-9 -�6 X Jdn 'o/'�� p�.st— 9CREEX19 INTWVPR- '(b OG fLA)66rO fII <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION g AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: G STEEL D PVC 0 OTHER: <br /> VAPOR g MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS u HOSE <br /> a AIR SPARGE]OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: aYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING n HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:—0 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> , ��Q� CO UCTOR CASING PROPOSED (if YES list speciBcat ment section) <br /> COMMENTS: ��t- /'- - - `- L`'- <br /> NOTE: OFFSITE BORINGS REQUIR 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 �Q 'PI2 <br /> Tftle/Company 'Pg --r i1/tmigic'n— <br /> PrintNam( J,IFI S02—T Date 3- 2q-off <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED': <br /> Application Accepted By Date Issued 3.127/06Area 9? <br /> ,7 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date WIlloi, _f., <br /> COMMENDS I CONDITIONS: C /31 5 6l YFS(a f r•�'LP <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> aRoz 60°° 6D� �Z`f�9 <br /> 9L SR# ao 6Z <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 />