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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ORIGMAL <br />SITE <br />MITIGATION <br />�%,( `� UNIT IV <br />��E4� <br />OUII <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. �TViis appli An Q r n compli ce with n <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental �"artment. <br />Ad <br />�" <br />PER17_ ENT "yds s <br />WELL Location;Z675 CoaHiyy t✓Iub 91M Cross Street IM <br />� ngTk Ad City STDGF-MA Zip 15/ V/��i � <br />PROPE TY , rr G <br />r �9 Q M G TtvD h S o Address 1! 9 POST b416-61Vc 1110 City tf oLtSra^ Zip77oS6 Phone# <br />C-57 Contractor i l II Address o #Opwt /Fve City arr At zip5-ic# SS Phone#VY-313- 5sbo <br />Consultant / Sub CTfu (�41AAIrICA Address,270 f'erki'M 9, City 70 a4AO( Lic# Phone# <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL 1 RnRING (CPT, GEOPRORF, HYDROPUNCH, HAND -AUGER, OTHER') (DESTRUCTION (choose type below) <br />0 SOIL BORING # `OVER -BORE. DIAMETER > (0 \J-) <br />0 WELL # 0 PRESSURE GROUT <br />O'Other GROUT SPECIFICATIONS <br />V^bCOMMENTS: USDA Stet (Nab' XIV -HJR. Ll AA) .AY19UT�b I%+�-Lt1 <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS -2� <br />`"MONITORING <br />HOLLOW STEM <br />DIA. OF BOREHOLEY MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA. <br />REC'D BY <br />0 EXTRACTION <br />AIR HAMMER/DRIVEN <br />CASING THICKNESS 6JA HD TYPE OF CASING: 0 STEEL �KPVC 0 OTHER: <br />0 VAPOR <br />() MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS <br />0 OTHER: <br />0 OTHER <br />APPROX. BORING DEPTH a6' 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 Ordina c gulations, and all applicable California State Laws. <br />Signed � VF Titic/Company IF�/ -/(kr <br />Print Name l_S Date % <br />DEPARTMENT USE ONLY <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE -VICE EST # <br />INVOICE <br />JO �, <br />�``" <br />-4� <br />SR# 3� <br />C-57 WC 10�' -WAIVER_ C-57 Letter of Authorization to sign permi-Er��monf-doc <br />EHD 29-02-001 <br />9/30/2003 <br />