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an Joaquin County <br /> Environmental Health Department <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITI ION <br /> w <br /> (209)468-3449 Fax: (209)468-3433 Web: w-ww.co.san-joaquin.ca.us/ehd JUL 0 7_ UNIT IV <br /> oR ENVIRON <br /> - NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SER HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application iaddeVi C'c�Mpliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of Stan Joaquin County Environmental Health Department. <br /> /�tt e f &)f�0 )den 41 5bce� OS Parcel#Assessors/L8 <br /> s y 3131 d y <br /> WELL Location 3U�a 1-^_"�Q � Cross Street City Zip <br /> PROPE�ar i, �` rr tt (�,- 1 n �/ / <br /> Owner Cr ink A-P- ayll)eZAddress` 383 6DUtbe�ree�CityST �ip��Phone#O - / -`/!,�(p� <br /> C-57 Contractor T �7lm(� 6ILT r�](Address S57 S Its�71b City :�JJ Zip Ellehone#_4i.7/ek-Z <br /> Consultant/Sub Cntr !SL&PU, Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/BORING. CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORINGo�;� 0 OVER-BORE. DIAMETER <br /> b WELL# 1111 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Aw- <br /> a <br /> -0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -)61 TREMIE TYPE TO BE USED: JYAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE )CPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPT KIS 301) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS P0r_TL/yU1) C Er7Y'�r+f <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH S'--5'0 / 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> - rT <br /> CONDUCTOR CASING PROPOSED Am (if YES,list specifications in comment section) <br /> COMMENTS: � l �G GAY`-1NL'_5 L`5 h�S' So/ vE��J Sf IiVI-K �-,/L'z />�'T1fE�i � <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 Ordyznces, Rules and Rera�u"llaations, and all applicable California S ate Laws. <br /> Signed v 7 -7'1"" Title/Companyy'elr- tVU7— <br /> Print Name / 1�Ltcy 5�, Date ZA/`7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 30 ( a' E L <br /> WORK PLAN DATED: ado t <br /> Application Accepted By Date Issued '7 L(/a T Area 2� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 63 SR# t33-71 <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 9/30/2002 <br />