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0;U'N..�o ,,an Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.co.san-joaquin.ca.us/ehd UNIT IV <br /> FC5 <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 made 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 /> WELL Location QCt-C& Cross Street City '"hj3�n_Zip9UL Parcel# <br /> PROPERTY CI f� �OC� E! 3 A <br /> Owner Address CityZip Phone# <br /> C-57 Contractor bfl c� Address 3Y7 5Vo�, City `� -,Zip c A-6:ic# �7Phone#��o��/CXY <br /> Consultant/Sub Cntr c7C-q�_ Address City ±� Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING ((3 T,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# a OVER-BORE. DIAMETER <br /> WELL# a PRESSURE GROUT <br /> 'Other GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE l aSa MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS - "—TYPE OF CASING: O STEEL 0 PVC G OTHER: <br /> 0 VAPOR 0 MUD ROTARY 'DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS Q HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes No (aNOTT�E: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING p HAND AUGER GROUT SPECIFICATIONS o <br /> a OTHER:_G OTHER APPROX.BORING DEPTH <-t Q Q BOLT D TRAFFIC BOX or Q 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 O finances, Rules and Regulations, a d all applicable California State Law . <br /> Signed x Title/Company V) e , <br /> Print Name l4`. Dae <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: a5 00ct <br /> WORK PLAN DATED: U <br /> Application Accepted By Date Issued G 3 Q Area <br /> Grout Inspection By Date 05� Final Inspection B ETEIODate <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 /> ado( �� �� 3,64 1SR# -9a � <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc / <br /> EHD 29-02-001 �•�P Y <br /> 9/30/2002 <br /> FILEO <br />