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San Joaquin County <br />Kcn'+q;i; ORIGINAL <br />Environmental Health Department MAY 12 2004 SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95YkIRONMEN1 HEA MIITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.co.san-joaqLlin.pfpkqOSERVICEC UNIT IV <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 <br />jTitle, JCfhapter 9-1115.3 and the Standards of San <br />�Joaquin County Environmental Health Department. <br />Assesso <br />WELL Location .� 1— / ! • Cross Street �17w c1✓� City J i L Zip 5�7 Parcel# rs J r ✓ (V ' b <br />PROPER <br />Ow:TY C��e_Y <br />Zipq <br />Phone#Yf vd�D-� <br />C-57 Contractor 4-e' 'br; Jl"a ddress/rif"011 SY <br />• City t' Zip�Li��Phone#�k" - <br />Consultant / Sub C <br />GIS Coordinates: X <br />dress ��= N�`' - J () City Lic# � � Z.I:: ' Phone,0?,e:3 q (� � <br />Township <br />Range <br />Section <br />WOK TO BE PERFORMED: <br />4 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />a SOIL BORING # a OVER -BORE. DIAMETER <br />ELL # A A 0 PRESSURE GROUT <br />*Other GROUT SPECIFICATIONS <br />COMMENTS: <br />T P I CRT P CONSTRUCTION SPECIFICA71ONS � <br />/IONITORING (2�OLLOW STEM DIA. OF BOREHOLE " 0�M/ULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br />ION MER/DRIVEN CASING THICKNESS�� _7 �' TYPE OF CASING: 0 STEEL 'PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED:AYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS( <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH PS 30/ 1U-96LTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSEDJV-' (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 />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinance es and Regulations, and all applicable California State Laws. <br />Signed �' C` Z�'"!i`�%��"" Title/Company P1..*:SEC I%}%V/4C7t1� <br />Print Na <br />Na <br />J &'Gf jj e -)CI- tJS <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: /--l / <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />Date Issued_ <br />,ate L u O Final Inspection By_ <br />5, <br />Area <br />Date /O u <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />SR# 3SO19 <br />C-57 V WC V -WAIVER_ C-57 Letter of Authorization to sign permit—j' <br />ermit Encroac men oc_ <br />EHD 29-02-001 <br />9/30/2002 <br />