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San Joaquin County <br /> ET� amental Health Department SITE <br /> y' 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (Z-09�4%8i34W.Tax: (209)468-3433 Web: www.co.saii-joaqLiin.ca.Lls/elid UNIT IV <br /> Cl Tf�FEPWI ABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �r=r.P�iiT;SE�; - <br /> Application is hereby mad >`o 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 /> �� 6�- <br /> w� <br /> //// CrA Assessors <br /> �T <br /> WELL Location "n ,' Cross Street ��/ City V4..( Ql _,,__zip />_ parcel# /VA <br /> PROPERTY I <br /> Ownerz'-' { �e(e( // ddress 19760,L r �tlaCvt City Zipt�Phone# 7 11 g 36� <br /> C-57 Contractor QlA'j Lp ddress/ ��� � Jd-' <br /> 6 City 0e0xA Zip�ic# ;O Phone#�0-237 11S�7SJ <br /> Consultant/Sub Cntr Address - Lic## Phone# M,6-771-r7_35- <br /> GIS <br /> 6-771-x735- <br /> GIS Coordinates:X Y Township 3S Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 5Q- 17 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE Z 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:NA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS i.; TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL +�2f4,I TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes '�No (NOTE: MAXIMUM FREE-FALL DEPTH I 301) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS l�fJ i,ariv�+l <br /> D OTHER:_0 OTHER APPROX. BORING DEPTH e,,;-0 0 BOLTED TRAFFIC BOX or 0 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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinance , Rules and Regulations, and all applicable California State L ws. <br /> Signed x F ` Title/Company L I L <br /> Print Name_ �� Ic��'1.^S Date d <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By ° Date Issued_ f l Lo�— � <br /> Area7� <br /> Grout Inspection By 1J' �^"�����( Date / Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: CD. <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 90/ 0115 00o1q'V?73j 6� SR# Do q1 3 9*;L-� <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 />