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�n Joaquin County Y <br /> > p <br /> G �����l�onmental Health Department SITE <br /> lbb eberAvenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> —P' ?��AR(?09�ff 449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> ENVIRONMENT HEALTH ell Permit Application <br /> PERMITPRA t�jIDABLE 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 9-1115.33/and <br /> 'the Standards of San Joaquin County Environmental Health Department. <br /> GU�CcY����� `fta`srt — 3G Assessors <br /> WELL Location Cross Street ?k-w . CityT <c c c!- Zip Parcel# <br /> GG l��j-' 9PRPRTY � %3 <br /> OwoerE 6./�I_ /'`/fir lV7� ddress y� L• � sr• City r�i�G Zip C' hi e# <br /> C-57 Contractor / Address .)162 q,1 L 4 4-v,,_ City 'amu„c1-5 Zip Llc# ��5 Phone# <br /> Consultant/Sub Cntr �1�� i� 6i n Address CCity 1��,.S nLic# Phone#9Z5 'GZ <br /> ri w��� Stc Zi(o <br /> GIS Coordinates:X S y 30 Y 2,t 13,2 1 TowrYstSip ZS Range Section <br /> WORK TO BE PERFORMED. <br /> c;NEW WELL /BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> ;tSOIL BORING# b 4' 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> MMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ]MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE y 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> ] EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /L(�; TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> ]VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ✓ �c2 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> ]AIR SPARGE/OZONE�PUSH POIN GP r CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ] OIL BORING 0 HAND AUGE GROUT SPECIFICATIONS t I-Z' <br /> ]OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> :OMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> 3ounty Ordina ces- Rules and Regulations, and all applicable California State Laws. <br /> Signed x �-- Title/Company �1� �/ &fs✓ <br /> Tint NBe /�� ✓r /�/!�U � <br /> /"t� tr-e � Date 3��s/o.s <br /> �J��'L r1 �( <br /> DEPARTMENT USE ONLY <br /> 31TE MAP IN UNIT IV FILE, ADDRESS: G:ab F I/ C�G �ZP� <br /> /YORK PLAN DATED: D <br /> application Accepted By Date Issued 0-05 Area <br /> 3rout Inspection By Date Final Inspection By Date <br /> -)estruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encrrea m nt doc_ G G <br /> EHD 29-02-001 �� , <br />