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12 04 2094683433 FIFTH FLOOR PAGE 02 <br /> WELT -'ERMIT APPLICATION F-`�M SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT N <br /> 304 E.Weber, Third Floor, Stockton, CA_, 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 TEAR FROM DATE ISSUED <br /> Appllcatlon is hereby made to San Joaquin County for a permit ED construct and/or install the work described. TNs application ss made in compliance with San <br /> Joaquin County Development Tittle,Chapter 9-17153 and the Standards of San Joaqutn County Environmental Health Department- <br /> U-niu W Assessors Location/6.1- tff�mLAU� Crass Street city P� ip Parce#.2 <br /> �_0 ' z.0 <br /> PROPERTY f� 1 /� 6,f -7 <br /> Owner 6 Ala _c Li Address&Q� �(C DY1. !_0 Cstyt k MTS Zep Phones 9,150 417r 7 <br /> C-67CorrtaclDr ro LXfldlyUj Address _60 ct 4 `n�zztp' ss3ltCa9�1�s Phor� -3�3- <br /> Consultant!Sub CntrDIfcZ.&W Address PO <br /> CftyiLsew.a� UcN Phone#707 'q3--4?- <br /> GIS Coordinates X "Y Tawnshwp Range Section <br /> WORK TO BE PERFORMED <br /> &NEW WELL I BORING (CPT,GEOPROSE HYDROPUNCH,HMD-AUGER,OTHER`) g DESTRUCTION (goose type below) <br /> (]901L BORING# 11 OVER-BORE DIAMETER <br /> )MWELL# - (]PRESSURE GROUT <br /> a'Other GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> rMONITORING XHOLLOW STEM DIA.OF 8OREHOLE_XL 1]MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA 2 t <br /> )EXTRACTION p AIR HAMMEWDRIVEN CASING THJCIWESS 1t�TYPE OF CASING 11 STEED. VWC 0 OTHER <br /> )VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL.1--(CL _TREMIE TYPE TO BE USED- TAUGERSd�S:�iOSE <br /> ]AI PARGE/OZONE [I PUSH POINT(GP orCMGROUT SEAT.PUMPED q Yes�to (NOTE- MAXIMUM FREE-FALL DEPTH IS 30') <br /> ] ING Q WAND AUGER GROUT SPECIFICATIONS <br /> I O ER—_ R OTHER APPROX BORING DEPTH_, �Sr �oi_T zD TRAFFIC oox or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ty,O (if YES,fist specillcaeons to comment section) <br /> :OIiIINEN7S: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 46 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> hereby certify that I have prepared this application and that the work Will be done in accordance with San Joaquin <br /> ;ounty Ordinances, Rules and Regulations, and all applicable Califomia Stale Laws. <br /> dgned xS�4a4--C� e �T TitlelCompanlr t t <br /> ^M N� � ��S C�� Dale 0.'3 <br /> DEPARTMENT USE ONLY <br /> -ITF MAP IN UNIT IV FILE,ADDRESS: / 4 D S ' <br /> YORK PLAN DATED:_ ",ra1,rf,rt 1 Qe3a .3 <br /> pplication Ac mpted Bir —Y d 4L_ 1Ay-e-a r4-"C e Date Issued _ Area s <br /> soul Inspection By Date Final Inspection By Date <br /> estruchon lnspeCbon By Date <br /> OMMENTSICONDITIoN5 S YL I <br /> ACCOUNTING ONLY AID* FAC# <br /> PE CODES FEE INFO AMOUNT REPAn TED CHECK# RECQ BY DATE F ERMIT I SERVICE REQUEST# INVOICE <br /> 1 BQ, oa 89 co / 8011 SR# 60 377 82 <br /> -57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />