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San Joaquin County <br />Environmental Health Department <br />600 East Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Wall Permit Annlirratinn <br />DIM <br />, % hlyg AL <br />E �MITIGE C�`—' <br />OCT w 4 260YNIT IV <br />ENVIRONMENT HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT,/SERV!�r <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 />Assessors <br />WELL Location 1315-4f. 6/r-111/4 S7. Cross Street C<s r S_/. City 11-a l Zip '75'!C74 Parcel# Z 3 3 ' 3 70 -0 `? <br />PROPERTY /r�� ✓' �� <br />OwnerCO,I/ted Sc«vim+%,0,% t Address/9'75'W. City �/�� Zip`,137L Phone# k3C, -3Z'; <br />C-57 Contractor �s� Address 2Z0 Al, c"a'/Sf Citykyo i�ahrl Zipf-f779, Lic#*eZ331Phone# 53y tF8 1yZ�t <br />2u2 V'-1 IJe~i-1 <br />Consultant / Sub Cntr r IZ4 Address Ai 4 , SW City si'x e4_7 Lic# Phone# ` i- 33 fri <br />tl � <br />GIS Coordinates: X 31% o Y " V . '(� Township 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 # 0 OVER -BORE. DIAMETER <br />WELL #� 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS:_ M, Z,, �li!.+►r %%;ori <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE 6L 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: Z_ <br />0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS Sit, -to TYPE OF CASING: 0 STEEL J(PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL2-3 At TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ��t'�-+•t' 6'A -w. -V <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH ,g$OLTED 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signedx' r Title/Company Cds�s%i, -�rwrr ce /%sSVC.. <br />Print Name /JL'& Date 101Zy1p7 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By� <br />Destruction Inspection B <br />COMMENTS / CONDITIO <br />DEPARTMENT USE ONLY <br />315 C. 11*"I-I, <br />/0.7.• 0-7- <br />Date <br />Inspection By <br />06 <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / EQUEST # <br />INVOICE <br />CJs E+±RSx <br />3&a <br />C-57 ✓ WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit_ Encroac ment docWiA <br />EHD 29-02-001 WEB <br />9/11/2007 <br />M <br />