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non Joaquin Count <br /> - - ' <br /> Environmental Health Dep i-tment SITE <br /> 9 600 E. Main Street, Stockton, CA 95202-.3029 1 u <br /> MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: «r w.sjgov.orglel?d T.,vUNIT I1/ <br /> t <br /> \L! `_i i ".I i1 �.i;•moi Ii -; <br /> VIlel! Permit Application .ry <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 /> ,,77 j ..,,�� �., _ Assessors <br /> WELL Location .0 lnn�l'$�Gu'.�F Sl�'C�iCfoss Street �! (tel' �`�. ity C�l.�'Tc+� Zip S L'S Parcel# /�� fin U 7 <br /> PROPERTY. t? ISP 52e+�$ D 15 tA) 40-r' <br /> Owner - Address ��� J f LL4Zip G} ( _Phone# <br /> C-57 Contractor Y � ✓� Address 3b it' /W ;'� 1 �s.j. City!4 e-S Zip25'v1b Lic#_,� -)y'`Phone# JI,� 6'$f' <br /> Consultant!Sub Cntr_�=rev;),�>-�c=rr'�ff <br /> J <br /> Ltic Address fit` !_ •y Z�f � ity r�i':/�- Lic# Phone# Ja /76,31 <br /> I <br /> GES Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 001E BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SF=AL TREMiE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE!OZONE BUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS e� Cw ea.r� �✓v � ! <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH � i �J s r 0 BOLTED TRAFFIC BOX Or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: I?{S L'V' 'r s-,i'l ;? <br /> t ! <br /> a <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. i <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina ces��,11 Rulesjand Regulations, and all applicable California State Laws, <br /> Signed X- fd�'"/ c�"� Title/Company. <br /> Print Name G ) c% Date 2Z22-/O F f <br /> DEPARTMENT USE ONLY <br /> SITE MAP M UNIT IV FILE, ADDRES : <br /> WORK PLAN DATED: !0 r5 f <br /> Application Accepted By Date Issued tP d Area <br /> Grout Inspection By Date ig 07 Final Ins ection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# j <br /> PEI.CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY I DATE PERMIT/SERVICE REQUEST# INVOICE l <br /> � 3 <br /> got q. <br /> 3 SSS 7rr� 5R# 53�5a <br /> f <br /> C-57T WC=WAIVED C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> t <br /> E-HD 29-02-00 l web ? <br /> 6/22/04 <br /> 1 <br /> II <br />