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San Joaquin County <br />EC"-nmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(T-09' 46834 iax: (209) 468-3433 Web: -vvww.co.saii-joaqLllii.ca.Lis/elid UNIT IV <br />ff VROJA'' is kL+1P 6Y BLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />pC:nNO, iT-'t, <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 />��// �,i Assessors n <br />WELL Location /Twp S3 /MP 0. /6, -Cross Street � // City �1L(�i S Zip i > `);5LParcel# AIA <br />PROPERTY 4/' <br />Owner/ --J,{ /1,9,t. of //�^3Asf�i7lddress/176�L r -kk✓3 City D Ziptj%5" Phone# 7o9- it - <br />C-57 Contractor //l�,s�d�l Q���ta �O�ddress/ d�� A'J City a//l�'Q+f�(Zip iul�ic# ( 5 Phone#0-237lij�75 <br />Consultant / Sub Cntr �A I- Address ZV 4.lc.ffAvGf/el✓D City McL.nsafo Lic# Phone# M9-777-.r735- <br />GIS <br />9-777-.x735 <br />GIS Coordinates: X Y Township Range 6� 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 # SE`S - 1-7 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />-- <br />It <br />6 <br />CONSTRUCTION SPECIFICATIONS qq 1 <br />DIA. OF BOREHOLE L 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ILS C J� <br />CASING THICKNESS K; Fac TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL +L;'t,3 TREMIE TYPE TO BE USED: 0 AUGERS -HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes WNo (NOTE: MAXIMUM FREE -FALL DEPTH I 30') 1 <br />)'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Jr <br />0 OTHER:—O OTHER APPROX. BORING DEPTH BOLTED 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 />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinance ,Rules and Regulations, and all applicable California State L ws. i <br />Signed x � Title/Company � G�, <br />-iL <br />Print Name l {�1,��'1 n 5 _ Date Z�75 f �i5 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By _ Date Issued 11, /Us— Area 9 1 <br />Grout Inspection By --LL "^-L Date I 1'> Final Inspection By Date <br />Destruction Inspection By Date �J <br />COMMENTS /CONDITIONS: L0 n1g1-t <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />RMIT /SERVICE REQU <br />INVOICE <br />SR# Daq1 3 S 7� <br />C-57 WC= WAIVER_ C-57 Letter of Authorization to sign permit –7Eercroachmen-t- toe <br />EFID 29-02-001 <br />9/30/2002 <br />