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JrU VY I T4i" Joaquin County <br />>rvpnmental Health Department SITE <br />304 East giber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />EN109)j4b;'8 4q -f,{4;. 209) 468-3433 Web: www.sigov.org/ehd UNIT IV <br />PER P';T'S <br />;� ,;!W6il Permit Application <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 />r, Assessors <br />WELL Location 9�L (}arc)p,�u; ��`C' 1 Cross Street I ��o"a<IaCity `S�oc �hjr\ Zip t�JL6 i Parcel# 02O -O+ <br />PROPERTY <br />Ownerr.j ks, �L,E✓�y= Zip s7- <br />C-57 Contractor—Cu S CCA. CAL Address SCS 5a0Mtc_ Circle City RaLInoL'rcl0p2i 76 Lic#-�I7-J/6'Phone#/6-G�3S-11C�`l <br />Consultant / Sub Cntr ` c wr (v`(fCoc hddress 3u1} L, CityR°"'d- 64o,,-Lic# Phone# -U c/00 <br />GIS Coordinates: x-12-1,.2-'150-';1 -7- , Y,3 �.�j(, 7l `6100 K , Township �-11% Range E Section �g <br />WORK TO BE PERFORMED: <br />X NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") <br />0 SOIL BORING # <br />[WELL# -'1 <br />0 'Other <br />COMMENTS: <br />C <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />$,AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPI <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER: <br />0 OTHER <br />COMMENTS <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />CONSTRUCTION SPECIFICATIONS ,, <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:__ <br />CASING THICKNESS`=1c lnecl,L-cAe&t'PE OF CASING: 0 STEEL J(PVC 0 OTHER: <br />DEPTH OF GROUT SEAL 3'�f (- TREMIE TYPE TO BE USED: A AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes Q No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS Por C e_cn✓__n � l I )p C- 1- CV-r--QfA L <br />APPROX. BORING DEPTH `ID (,-.et- lx 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED /y,j (if YES, list specifications in comment section) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT 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, Rules and Regulations, and all applicable California State Laws. <br />Signed x `-��/�� l''tT�y�- Title/Company <br />Print Name Vi LVU,r � �- Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: I C, Mme [' A " 1,J,"x1i- <br />WORK PLAN DATED: �> rj , Z C C`{ <br />Application Accepted By Lt�A./J/V L - j Date Issued Z , 1-_ Area <br />Grout Inspection ByLL�-V"Zl• C t -A Date 3 . Final Inspection By L,{ e ti,nC'r Date ' 10 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SER ST # <br />INVOICE <br />SR# I� <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 />1i <br />