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San Joaquin County <br /> 2$nvironmental Health Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> (20 .),46$-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <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 /> ssessoC 2. r_2-LiZ p0J6StCross Street CityS1ZCtIm Zip arcel# 2IWELL Location <br /> } <br /> PROPERT�Y� Ei /�—-;?j --0" <br /> Owner Address City Iwto Z �2" Phone#-Z0-_ <br /> % i��� \��I ���� �fk° �I��Lic#�T�uPhone# <br /> C-57 Contractor �1 Address J 'Y l City L ✓6� Zip w 1 <br /> Consultant/Sub Cntr l�lUt111n �+hprV,14ity t��r`AALic# Phone# <br /> GIS Coordinates:X'�ll t 10 337,4Y �'i,V'i6-,1 3�1'4ownship I V Range Section �— <br /> W <br /> WORK TO BE PERFORMED: c <br /> D NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") DESTRUCTION (choose t eyp belo ) l� <br /> 0 SOIL BORING# VER-BORE. DIAMETER V\C'kL <br /> D WELL# 0 PRESSURE GROUT <br /> 0*Other \ GROUT SPECIFICATIONS <br /> COMMENTS: ���AD�(1� 6� I" ► �/� y _ m <br /> 6 <br /> c� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i <br /> )R-MONITORING I OLLOW STEM DIA.OF BOREHOLE }L 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 211 `�- <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_S-k TYPE OF CASING: a STEEL �PVC a OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> D AIR SPARGE/OZONE 0 PUSH 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 <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or D 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 Jo:-VI"-1:41 <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. (l1_f I A44Signedx yTitle/Company 1� 1�/�,lr�i��Tiv ( �� �0/J 1 ,4 ��1� <br /> Print Name,' �� \( Date <br /> DEPARTMENT USE ONLY <br /> PAYMENT <br /> SITE MAP IN UNIT IV FILE,ADDRESS: RECEIVED <br /> WORK PLAN DATED: <br /> � �iY _Q_1 �� � Date Issued `� d �+' OCT Area 205 <br /> Application Accepted Bye <br /> Grout Inspection By J Date Final Inspection By4' tRUIN COUNTY <br /> Destruction Inspection By 4l.4r Date Iol/ O(, ENVIRONMENTAL <br /> HE <br /> sTl I BEf1hf1TMEPIT <br /> COMMENTS/CONDITIONS: LZ���i'Ysr� GSA -/ 'P-e B <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 44. 12— fo �Cr p SR#ply ��� 7 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />