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U San Joaquin County f R <br /> �i •� Environmental Health Department (o �sha „ 1 <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 ��— � � V �IGATION <br /> (209}468-3449 Fax (209)468-3433 Web www sjgov org/e"JUN 2 8 2D04 UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED"tic 1�1�� �i�l T HEALTH S' <br /> Uplication is hereby made to San Joaquin County for a permit to construct and/or install the work described fPhis appTica&cd \46fa$e in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> essors <br /> FELL Location `]Q� L Cross Street City ZIP arcei# z <br /> PROPERTY L���� . <br /> Cner�Jr}Y�1'1Q�CY's��r�C't� Address I3aU (t),1��,�} [City �7��C ZIp-$Phone# <br /> 57 Contractor ddress4 ' CI kff j�Zlp�ic# I ��Phone# of t�'P� <br /> 5+.910 <br /> Consultant 1 Sub Cnir i ce _Address"it bfdP�c]Cprui _Ciiy�Pf mOf1}tllic# Phone#g�_���1 <br /> 131S Coordinates X 'y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL 1 BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> 1)SOIL BORING# p OVER-BORE DIAMETER <br /> I)KWELL# thIL1- -,-)Q' n1W=Z0 a PRESSURE GROUT <br /> W"Other GROUT SPECIFICATIONS <br /> ItOMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> IONITORING X HOLLOW STEM DIA OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA <br /> r0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNES30giSO' TYPE OF CASING 12STEEL OVC 0 OTHER <br /> 00PIL <br /> OR 0MUD ROTARY DEPTH OF GROUT SEAL TREMIETYPETOBE USED 0AUGERS ,HOSESPARGE/OZONE pPUSH POINT(GP orCPT)GROUT SEAL PUMPED KYes p No (NOTE. MAXIMUM FREE-FALL DEPTH IS 30')BORING 1]HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER 0 OTHER APPROX BORING DEPTH -� KSOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br />,COMMENTS <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 applica n and that the work will be done in accordance with San Joaquin <br /> County Ordina s, Rules n egul ns, a all applicable California State L ws <br /> Signed x ./ Title/Company <br /> Print Name N�C_ Date Z� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: c ,60 <br /> SITE <br /> PLAN DATED: G-y y-o <br /> Application Accepted By x4AP1_ Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> COUNTING ONLY AID# FAC# <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 1 ?ltd -Z$ SR# �36� <br /> C-57WC -WAIVER C-57 Letter of Authorization to sign perrnitn' Encroachment doc� <br /> EHD 29-02-001 <br /> 9/30/2003 <br />