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Wan Joaquin County <br />Environmental Health Departmento f(�`l §S_ITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 4 ` (I 46(OATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Wpll Permit Annlir_atinn <br />SAN 2 9 2001 <br />- - - - - ' N"',kgMEfVT HEALT8 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PFRA IT pp,/I.� <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applica4ib'kis�Ward�g 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 11 '?lo W. (-OL�t.lSt Ave_ Cross Street Uti/o.� City H+*AJzfC,.A Zip 95336 Parcel# o217 - .?Lo - 2/ <br />PROPERTY A44. / <br />Owner �0 J� wt clA/n4j Address 1D1 k4CL S4 City Sriv 07.sc Zip '7512 /a 4o9- - 2p2'-(.777 <br />ySS16S <br />C-57 Contractor G„—toar !I, ua Address '?Sc)14o,a�£ A04-40Cityt!!!! Ne2Zip 9VrS.3Lic# Phone# %S -.3& - 5800 <br />Viot,.w *_ 1V//S BC.w1t44-./k Po -z4 G.c.lc 92S – <br />Consultant/ Sub Cntr cL as.+rf_ . avC . Address Sir:. ## � <br />/no Citywv,11 c Lic#,Phone# GV 8 - 200 <br />GIS Coordinates: X , Y , Township Is Range 7E Section 3.2, '11, 3e/ 2 7 <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) W DESTRUCTION (choose type below) <br />0 SOIL BORING # /g'OVER-BORE. DIAMETER Ja ” Aqr" <br />0 WELL # 0 PRESSURE GROUT / <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: -i- des "4 /j-// ?F Sp—re- &t, ,_ifs eN S. I_ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 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: 0 Yes 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 0 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 Ordinances, Rullesand Re ul ions, and all applicable California State Laws. <br />Signed x !P Title/Companycc�-1,Q 4 4t. -r— <br />Print Name C-�.. <br />le /-f�L�c.. Date /-•2.2 -.?on'! <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 119(. L sie,c,vr.. ot,, t cc <br />WORK PLAN DATED: v,/), <br />Application Accepted By (i Date Issued 2 ( O Area <br />Grout Inspection BDate Z O Final Inspection By Date 3 O <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: `6 OW. <br />ACCOUNTING ONLY: AID# FAC#Lr4L-/�C� <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PE�NFF� SERVICE REQUES <br />INVOICE <br />3 5.0 Z <br />60 -Co <br />S <br />I'o S R# <br />O (J <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit, Encroachment doc <br />EHD 29-02-001 <br />6/22/04 <br />6' <br />