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��llf� LL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY <br />MAR p 3 MITIGATION <br />ENVIR� 2044 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br />PFpM/T S /V R 7 HEALTH (209) 468-3449 <br />VICES <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 Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location t5o lI hCs� dJ//` �� Cross Street +1SCity � ssessors fj2,4bAarcel# (� <br />t <br />PROP <br />OwnnerERTM! Vt B f' Adclr�elss// ?-)p r / *-77q7 city nn �l Zip qS 7 Phone# �R� ?� 2 — G 04, <br />C-57 Contractorm LJ� r M l � Wl ress 706 /�%1'144 0%,' ity r , 0, Zip`/Sf 7(116 �1.2El Aone#4�%CD3/ <br />Consultant/ Sub Cntr V L Address -S k $I-0 - City Y �Lic# Phone#2,0� �tio 7 <br />GIS Coordinates: X Y Township Range Section <br />AID# FAC# <br />WORK TO BE PERFORMED: <br />FEE INFO <br />p NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) a-BESTRUCTION (choose type below <br />CHECK # <br />p SOIL BORING # Ag -OVER -BORE. DIAMETER �n <br />DATE <br />a WELL # jpll�ESSURE GROUT <br />INVOICE <br />COMMENTS: [ (� it CL— ' I �> �S C r; GROUT SPECIFICATIONS <br />('t ' <br />eit <br />�� <br />�I oil <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />1MIONITORING �1 IOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGSULTI-LEVEL WELL CASING DIA: �(1 ✓tC j.� <br />O <br />/ <br />a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 0 L U TYPE OF CASING: a STEEL D VC 0 OTHER: <br />IVAPOR a MUD ROTARY DEPTH OF GROUT SEAL 5_0 /=e2-"f"TREMIE TYPE TO BE USED: ,B AUGERS G HOSE <br />IR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: ees p No/ (NOTE: AXIMUM FREE -T=ALL DEPTH IS 30') <br />9. <br />0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS � •' "f' � �1.� <br />� <br />Q OTHER: a OTHER APPROX. BORING DEPTH [] BOLTED TRAFFIC BOX or a STOVE PIPE <br />�[�' y� CONDUCTOV CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: t' 3 K': 1 Z�') G� 66//,t% -C I 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 Ordinances, Rules and Regulations, and all applicable California <br />/State <br />Laws. �^ <br />Signed x V l�l�t�i�/ /�— Title/Company C /�"� / / (7'0 <br />Print Name' l[ Pr •'L—� {�� �� jt/�l— Date'3 V <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By�c Date Issued_ <br />Grout Inspection By Date I Final Inspection By <br />Destruction Inspecti, <br />COMMENTS / CONDITIONS: <br />IC <br />�/Loses <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />P <br />INVOICE <br />3 6 <br />('t ' <br />c "� <br />�� <br />�I oil <br />S R# <br />OD S <br />C-57 WC --WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc 9/30/02 <br />