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pan Joaquin t-ounty <br /> nmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> P r 2& 4682J Fax: (209) 468-3433 Web: www.co.san-joaquin.ca.us/ehd UNIT IV <br /> ��fF'dRN` <br /> EruV,hryl�r` <br /> 0F'JM/9-= ADABLE 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 /> _ Assessors <br /> WELL Location -? t4, %, �� Cross Street City 1^G� S zip Parcel# ZSS ��'ODSS <br /> PROPERTY / p / r <br /> Owner b jc,- C' A �wl,A ZV;Zg_Address r OKPK I Ib� City t-19-6A0/ Zip �t Z: Phone# <br /> C-57 Contractor �2G+3r M �� QNddress �� g� _ 37� /� 'ity ic/.v Zips�Lic# Phone# <br /> Consultant/Sub Cntr 5AIC_ Address 31W(n)i,-�r Ay ��City';Pz ic# Phone# 716-171 37 1 <br /> GIS Coordinates:X Y Township 3 5 Range 6 t✓ Section 3 <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) QCT'} (choose type below) <br /> OIL BORING# 5 - is,SI3- ly�50_11 S 5a- t% 0 OVER-BORE. DIAMETER <br /> ELL# .S�i-11 MW - - 0 PRESSURE GROUT <br /> Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS AA <br /> MONITORING XHOLLOW�STRA DIA. OF BOREHOLE " 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: N_A <br /> 0 EXTRACTION 0 AIR HAMMER/,/DRIVEN CASING THICKNESS_ TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER- <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS )IOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes )(No (NOTE: MAXIM�IM FREE-FALL DEPTH-IS 30') <br /> SOIL BORING 0 HAND AUGER ` _ GROUT SPECIFICATIONS RO /-4-4.0_.�.d <br /> 0 OTHER:_0 OTHER 6( � APPROX. BORING DEPTH S_O f-t- 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> / S/ CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> rC <br /> COMMENTS: z`� 9jel oT {�-I fL .t i A n O <br /> � 1 ') vv� u �a ,a s- f{�5v) IIQO�' y <br /> NOTE: QFFSITE�BORINGS� REQUIRACCESS AGREEMENT R ENCROAfMET 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 Joaquin <br /> County Ordinances, les d Regulations, and all applicable California State Laws. <br /> Signed x t' Title/Company <br /> Print Name Let- A.s Date Z �S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: / p <br /> Application Accepted Bygk�L_a� Date Issued �[l�d S Area <br /> Grout Inspection By Date gl q Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: !/l"t.Ur�c e,t.�!/ 4 AV. iy.,t4 K - <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 6001 �f <br /> S� �3 µCc �lr o1— sR# 13�o <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/30/2002 <br />