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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 9202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <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 />t _ Assessors <br />WELL Location `: r1ai� o-tcr Cross Street {C(-, > I (✓v,l PCI�� City �`ft�C K ��rJZip 5 001Parcel# <br />9S88 <br />PROPERTY 76 Broad t�ciy „�.{;cme,%h / <br />,�,� Sura - <br />Owner (..yrX-0 12hi Ilt PE� AddressCC y-z_;tT�t`°fei ZipPhone c '- y <br />n "�, c i <br />C-57 Contractor 6w r V^ Address C 1. QM jZ0C�[a�JCity jiCZip� �ic# (05 4 Phone#`0 5. 51 3. Js00 <br />Consultant/ Sub Cntr s[--(-C)(2-Address 3c± 1 7 k i IQm-(' f`a. City roe Lic# 3 > kPhone# (11(p. 8;01--0400 <br />GIS Coordinates: X L 4 4,9L -S- C , Y-� CL, C, 4 Sc i Township 2 N Range Section is, <br />WORK TO BE PERFORMED: <br />gNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />FEE INFO <br />SOIL BORING # L 0 OVER -BORE. DIAMETER <br />CHECK # <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />C <br />COMMENTS: `rZpyZ�yi: ' 5lLr�C'<c Sir" (YAYc4(aU' <br />fry—� <br />c <br />89.0d <br />C <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />sR# 003 8 593 <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE . l 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <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 1 17 TREMIE TYPE TO BE USED: 0 AUGERS `8�10SE <br />0 AIR SPARGE/ OZONE gPUSH POINT (GP or (PT)GROUT SEAL PUMPED: )Er Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS (�• `� ti 1(.k I Vj (P,) a, 1 It c ck i')x , 0 -In 1 <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH I. -)C rnC' X 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: CW,L19- <br />i <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 viiLLJ(al,S� L Title/Company e�3 eulo 5 <br />Print Name fn I !r K 4- L Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: t 144yn rjte r L <br />WORK PLAN DATED: WArA -2 <br />1 <br />Application Accepted By + w , M e- ifar Date Issued J v n e, ZS, 200 4 Area 14-' T 9 <br />Grout Inspection By Vi c+or cr< Ate -ed r�1 Date 7 / d Final Inspection By I/,`L' D� �>l� )"X -pate '616 <br />Destruction Inspection By^^ Date <br />COMMENTS / CONDITIONS: C C <br />/�t <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERV UEST # <br />INVOICE <br />350199.00 <br />89.0d <br />5-vI13 <br />1 <br />sR# 003 8 593 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroac men oc_ <br />EHD 29-02-001 <br />9/30/2003 <br />