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FILE COPY <br /> San Joaquin County G CEO�y <br /> 2 Gz� Environmental Health Department l� SITE <br /> W 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202aur 1, 6 200VITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> cac11R, P ENVIRONMENT HEALTHePermit Application <br /> PERMITVK-IVP ERVICES <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 ma a in co pliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of n Joaquin County Environmental Health Department. <br /> A Assessors <br /> WELL Location 12©1 0 , Pe,r61ei,,a AV'QI o <br /> .Cross Street h City s tocAgo,.Zip °ISa03 Parcel# 13 00' <br /> PROPERTY A 1 Ct Q <br /> owner C'& �� $'tocV-` 016, Address b E. 1—i r�Is-- >lfCity �torVt,-" Zii CkQ0 Phone# a0At n— V a0 ro <br /> 1` in 7 6"'M 0 <br /> C-57 ContractorLh.S, Ge�r(a icoti` $ r"I dress57Z S Vlit-P-kity owe ! vZip' al7'3Lic# NA Phone# �S� 637'QdO� <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X_ 37 S-7 3(o Y 12 l 18 5O Township I N Range G E Section 0 Li <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BO ING# 0 OVER-BORE. DIAMETER <br /> �1/VELL 3 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: `Nret a/11 XC&.- QVC "4.113 %ale,Zo cc-ree-^i i w 1 ��3���• X(,. �iop��a�c. 1✓QL� 6�fe e n <br /> i✓\ �t O— '1]—�L 7.Z ter_ A(Uu _ -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATI NS <br /> JKMONITORING 0 HOLLOW STEM DIA.OF BOREHOLE La ULTIPLE CASINGS 0 MULTI-LEVE/VIC <br /> ELL CASING DIA: <br /> c <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS O TYPE OF CASING: 0 STEEL 0 OTHER: <br /> 0 VAPOR 90"ROTARY DEPTH OF GROUT SEAL6c�e TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ees 0 No (NOTE: MAXIMUMFREE-FALLDEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Se-C Xr- (i'nvvx 50 ya 1-0 Li Lf `-f e Got <br /> 0 OTHER: 0 OTHER y-APPROX.BORING DEPTH G010 FRr- BOLTED TRAFFIC BOX or iKSTOVE, E <br /> / e CONDUCTOR CASING PROPOSED o.. (if YES,list s`�ecifications in comment section <br /> COMMENTS:_W�11 Ir aux y N�1 (� c�v.c t vas.IT. t--7 c.,.� 1b10 'Ler -1., ) <br /> J SO <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, RulWand Regulations, and all applicable California State Laws. I <br /> Signed x -'�Gti 1/'P/L Title/Company HfjSNlaca I j C'Ot" `L 6'-'e:17 <br /> Print Name LoTe,x hej;2 Q_( Date "5j- 160 aJ 05` <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: U`7(�5 — /lids " ��• <br /> WORK PLAN DATED" k.G <br /> Application Accepted By Date Issued � Area <br /> Grout Inspection By Date Final Inspection By GMEgMTERe <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroochme� doc_ <br /> EHD 29-02-001 �i / <br /> 6/22/04 <br />