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......... .. :. ... . . . . ... . . <br /> FILE COPY <br /> QD,N San Joaquin County% SITE <br /> �° o0 <br /> Environmental Health Department <br /> 2' Za MLTIPTIDN <br /> H' 304 East Weber Avenue, 3rd Floor,Stockton,CA 952 .,I�-, -` <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> C' . �P <br /> AGIFOR� - 04 NOV -) AM 9: 26 <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 m;+Je 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 /> u 1b22 <br /> WELL Location <br /> /-7� rC1G1'1C _Cross Street City�` �'E -Z�p��aO� Parcel# I CL <br /> .1t,I Phone# `�04 -'47 �'-1741 <br /> PROPERTY ernsi Q�'IOb OXx LCity �-F 4 >r"1 ZiP�'� <br /> Owner �'4C)j bCAddress <br /> �. �� Cl"2C �'ir^C1lZ City c v Zip RJ 1o0 Lidk'7 7 (OPhone# 9/CP Co3i l40 C? <br /> C-57 Contractor �O�SCAC�-� \�1UnQ Address-, oc o <br /> vrel Phone# 9Z CB a-710 Q <br /> Address/c"illS� a IO�Piyc'i he City Sic-mo++PukLic# <br /> Consultant/Sub Cntr `� <br /> Range Section <br /> GIS Coordinates:X Y.,Townships <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> EW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') no OVER-BORE. DIAMETER <br /> SOIL BORING# W U PRESSURE GROUT <br /> WELL# MW- R 1 k GROUT SPECIFICATIONS <br /> `Other <br /> COMMENTS: ^ 'SSYkLI— C-3 �32 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSLOPE OF CASING: STEEL PVC OTHER:E CASINGS U MULTI-LEVEL WELL CASING DIA: <br /> AMONITORING HOLLOW STEM DIA.OF BOREHOLEE.25" ru/ <br /> U EXTRACTION U AIR HAMMER/DRIVEN CASING THICKNESS b ISGI'S�4 a7Y <br /> VAPOR U MUD ROTARY DEPTH OF GROUT SEALI1"1 92('I TREMIE TYPE TO BE USED: U AUGERS >0 HOSE <br /> p AIR SPARGE/OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED:-g,Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING U HAND AUGER GROUT SPECIFICATIONS1r--A�, .r IBOLTED TRAFFIC BOX or U STOVE PIPE <br /> U OTHER:_O OTHER APPROX.BORING DEPTH /b. f'` <br /> CONDUCTOR CASING PROPOSED_ <br /> if YES,list specifications in comment section) <br /> COMMENTS: I1J- I �5''' O "� c> r <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 nd Regplations, and all applicable California tate Laws. <br /> Title/Company <br /> Signed x /r <br /> Date <br /> Print Name— <br /> DEPARTMENT <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: D <br /> WORK PLAN DATED: �j NOJ 2.ce) <br /> Date Issued '0 � <br /> , Area � <br /> Application Accepted By ate__� 1tj l <br /> Date Final Inspection By <br /> Grout Inspection By / 7 <br /> Date <br /> Destruction Inspection By <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE RE` <br /> 2`t0 REQUEST# INVOICE <br /> uJ �4• � SSI Cx t I( 5 SR# Q D3D7 <br /> C-57✓ WC WAIVER_ C-57 Letter of Authorization to sign permit ✓ Encroachment doc_ . <br /> EHD 29-02-001 <br /> 9/30/2003 <br />