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%an Joaquin County • <br /> y Environmental Health Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> •' -, "j (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehdUNI I IV <br /> yva on.- <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 /> i a,� SoL*vl FiI-,. _ -1.)yC y J p 3„i_ Assessors <br /> WELL Location ,�/�'"� / V t I,(,1��(.0 ross Street �� ✓1 Cit Zi ��Parcel# C+q UZ'UZ <br /> PROPE RrT,Y, �1 1 <br /> Owner W�U (�5 Address X711�� JAVI 1A k. city S�.to ZipJ-y� Phone# �CIu <br /> C-57 Contractor r 1�f'1 "��Address�b� �VY"r+ut, G(d e- Citt�� Zip"�S '�IZLic#��Phone# q1 I' /� <br /> Consultant/Sub Cntr t ka L-\j7j7y�fft"dIess��tl/M6,(�rY1d Ci/ty Lic# Phone# 7t Lt x'131–` 160 <br /> GIS Coordinates:X_j� 'p (I�._p{,Y 1)k'.L(d 3)i MW,Township �` v Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose tylle below) <br /> a SOIL BORING# / OVER-BORE. DIAMETE /T <br /> a WELL# a PRESSURE GROUT <br /> * GROUT SPECIFICATIONS <br /> COMMENTS*Other n - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> NITORING V110LLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> ( <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 0!1(1 TYPE OF CASING: a STEEL XVC 0 OTHER: <br /> a VAPOR o MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: a OTHER APPROX.BORING DEPTH L�© 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 thatj have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinance// les and Re tions,and all applicable California State <br /> ''Laws. <br /> ) I 'r <br /> Signed x ��— Title/Company C W`SV`�U t— t(il ALA <br /> Print Name—VA �ep 0a 1 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> �/ �ee �/ L <br /> Application Accepted By rU Dc/^P �K 7 6 Date Issued /)//,0/06 _ Area <br /> Grout Inspection By Date Final Inspection By. <br /> Destruction Inspection By f.+ ,fgeDate ILO-104" <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> yZ/ 40. ao 23-77 -2Z ti/7 L6 sR#oU� L l� <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 />