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San Joaquin County <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd 2005 MAR vml�: 01 <br />Wall Parmit Annlit-atinn <br />----- --- - - -- -- - ,- -- - - bA'i JC?.(:.'. iti C0UtjTY <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIROfdHENTAL <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applica font sLJAehiY-c "aTit4(iijSan <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />/ Assessors <br />WELL Location 3'715r JJ j�%/Q�L'Vj 7AL Cross Street VA IJ 16U"City 5T0611011i Zips_ Parcel# <br />PROPERTY P-6' feM- Zt (a ,.,, , l ?- / <br />Owner ELC�JSWI'an- Address 3 7� (� } � City 51 Zip Phone# MF- x%4'3 <br />C-57 Contractor tS(l//� .. / Address 3 042, G1/LlC,f. Cl/�'Cnt (�;I City + 6 ip 9J'iZPic# %/%S/C Phone# <br />Consultant/ Sub Cntr 1�1�G�VifV CPd Cay CLnv Address x,57 94&IL) P`-(,4 City Lic# Zz Phone# %- 160 <br />GIS Coordinates: X , Y , Township <br />Section <br />WORK TO BE PERFORMED: <br />`©,NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING# 0 OVER -BORE. DIAMETER <br />WELL # I'�Lv'4 109 11.17- (O�N O PRESSURE GROUT <br />] *Other T� GROUT SPECIFICATIONS <br />COMMENTS: _ U� <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />It <br />'MONITORING <br />f HOLLOW STEM <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />DATE P IT/ SERVICE RT # <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS S 1 TYPE OF CASING: 0 STEEL ,,PVC 0 OTHER: <br />-- <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL 4PPaGX 1&" TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes Y No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS POP-rLM'y P LCMt%L <br />0 OTHER: <br />0 OTHER <br />APPROX. BORING DEPTH JfL 1 j- BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED NO (if YES, list specifications in comment section) <br />n <br />COMMENTS: t O�N�15 iial - f5 I,r�JI/fte7m <br />E'S M( Aj WiiZLS fiQ&C-1) 00("J i?r? i+ &,5S64t-VATrVA)S <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 Ordir}agces, ules and Reg tions, and all applicable California State Laws. <br />/�; / <br />Signed x 7 //1✓t ,� �- Title/Company �, ! <br />Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />ZZ - <br />Application Accepted By T� �� Date Issued Z- V Area -/ <br />Grout Inspection By e Date 3 12-1 0S"" Final Inspection By Date V 2,9 10C <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: 'OF .5,7ft <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P IT/ SERVICE RT # <br />INVOICE <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_ c <br />HHD 29-02-001 <br />6/22/04 <br />