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PQW San Joaquin County <br /> V .< �. "o <br /> Environmental Health Department o' 61 I I_TE_ _ <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> Ei�4 ,a <br /> (209)468-3449 Fax: (209)468-3433 Web: www.co.san joaquin.ca.us/ehd NIT IV <br /> _ P MAY 2 7 200 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT H <br /> Application is hereby made to San Joaquin County for permit to construct and/or install the work described. This applicaoEF4 /ji' n th San <br /> PP Y �r11 VV�i <br /> ty P <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Departmenf. <br /> Assessors <br /> WELL Location a�"nn r ]��t1Z� Cross Street City s�.�� ZipCl 09 Parcel# _j37-6 ;)L6- 1-(2— <br /> PROPERTY <br /> Owner---�LD g ivt' t, address 3a3 (Y)aiW g1— city !t�4bc-Lb'V\ Zip Phone# O� -13S <br /> C-57 Contractor ft(5)L Address 1337 5Y�/�-� ^ City S ICfi�Zip 1";X"SLic# Phone#(20 <br /> Consultant/Sub Cntr Se'.Vim' Address City Lic# Phone# <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW ELL I BORING (C GEOPROBE,H DROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> SOIL BORING# p OVER-BORE. DIAMETER <br /> 0 <br /> WELL# a PRESSURE GROUT <br /> p'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> g MONITORING a HOLLOW STEM DIA.OF BOREHOLE L 2f a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESST_�h NPE OF CASING: 0 STEEL G PVC G OTHER: <br /> Q VAPOR ` 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes *o (NOTE: MAXIMUM FRE ALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS / ` Oft <br /> p OTHER: Q OTHER APPROX.BORING DEPTH /() Q BOLTED TRAFFI BOX or p 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 application and that the work will be done in accordance with San Joaquin <br /> County Or .i ances, Rules and Regulation , and all applicable California State Laws. / <br /> 1t^-c c 'l <br /> I Ul <br /> Signed x c n y Title/Company <br /> Print Namel\ <br /> _a � y101- z��lr L _Date <br /> DEPARTMENT USE ONLY <br /> i <br /> SITE MAP IN UNIT IV FILE,ADDRESS: GC C <br /> WORK PLAN DATED: 5- <br /> ?application Accepted By Date Issue Area / <br /> Grout Inspection By Date — 0 Final Inspectio X7MDate_O�VW <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITT4CHECK# RECID BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> � a ( ,�� $ 3 sR# 3'92(Q7 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroach o <br /> EHD 29-02-001 -copy <br /> 9/30/2002 <br />