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*an Joaquin county <br /> Environmental Health Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> (209)468-3449 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 tth{e Standards of San Joaquin County Environmental Health Department. <br /> WELL Location <br /> 322 �( � tVi(�� } C oss Street v Cit y 9�W Zip Assessors <br /> Parcel# <br /> i r <br /> PROPERTY <br /> Owner tSQ (,(C /5 AddresstVC���I)��t���®m, (. CityZip� Phone# � �5 <br /> C-57 Contractor � Address C r&� G�(��e Cite Zip`IrrffS-X12Lic#j ��Phone* �1I, (01 <br /> Consultant/Sub Cntr U�A�/� C1�1� ����JQ2r�ess�'lV (JlC `rYttk��CiittyWGl�Lic# Phone# '-71L4--q31-q160 <br /> --q31-q16® <br /> GIS Coordinates:X �"U. �® el ,Y 1110 'Z ,Township ', v Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose ty a below), <br /> Q SOIL BORING# OVER-BORE. DIAMETER i ILt/-(/t <br /> ®WELL# ®PRESSURE GROUT <br /> ®*Others !GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> NITORING X-IOLLOW STEM DIA.OF BOREHOLE p MULTIPLE CASINGS ®MULTI-LEVEL WELL CASING DIA: 02__ <br /> ®EXTRACTION /0_AIR HAMMER/DRIVEN CASING THICKNESSI {11 w/ TYPE OF CASING: ®STEEL VC a OTHER: <br /> o VAPOR ®MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> a AIR SPARGE/OZONE ®PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ®Yes o No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING o HAND AUGER GROUT SPECIFICATIONS <br /> ®OTHER: a OTHER APPROX.BORING DEPTH Ri ®BOLTED TRAFFIC BOX or a 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 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County OrdinanC les and Re tions,and all applicable California State'tLnaws. e P <br /> Signed x Title/Company C IN ISL)� U �� <br /> Print NameV Date �L <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED�:/ "' " <br /> Application Accepted By Awa&C ,tom. ¢ 2210 6 Date IssuedArea <br /> Grout Inspection By Date Final Inspection By. <br /> Destruction Inspection ByA4f �Date l 01 <br /> COMMENTS/CONDITIONS: ?��aK° ?�fes/_27 v <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ao 12377 /1/7 ®6 SR#Ooq 88 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 r (} <br /> 6/22/04 <br />