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REr Joaquin County <br />Environmental Health Department <br />[rIA04-East-,Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />X09) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Pr `. r l Weh1Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />6N-CP7- <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 />FEE INFO <br />Assessors <br />WELL Location --fZ7,2-jr—u r < «J ;3tv A Cross Street V- j,' 14 r City -Zip Parcel# t t <br />REC'D BY <br />PROPERTY <br />VOICE <br />Owner 7—t( Address6,OX -ZtI City�,ji45 Zip7VZZ% Phone# <br />mol;_l <br />C-57 Contractor arP4o, �! ui� Address R4'IS- C.efr }vsA4oe City ;j`,41 ff;11 Zlp `/-0006 Llc#6'Sby07 phone# 5-b2--'12-7-6-6`97 <br />Ctionsul it/SubCntrs� Address 30r�7 kau3✓c City!- -1004i Lic# Phone#`*b YW-0yo0 <br />GIS Coordinates: X Y 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 />0 WELL # 0 PRESSURE GROUT <br />0 'Other GROUT SPECIFICATIONS <br />COMMENTS: <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 />R SPARGE/ OZONEAPUSH POINT (GP or CPT)GROUT SEAL PUMPED: A Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />,,,,,.,OIL BORING, 0 HAND AUGER GROUT SPECIFICATIONS /Qea 1- C e #H e A t <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH % t0 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED tiv (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, Rules and Regulations, and all applicable California State Laws. <br />Signed Title/Company 5f':t% GieDiof�rt - 5 ��2 <br />Print Name S> 4L ik c - - - _ Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: Z e <br />_ Z I —� <br />Application Accepted By Date Issued / Area <br />Grout Inspection By Date Final Inspection By Date ��5 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />CODES <br />FEE INFO <br />AMOUNT REMITTED CHECK # <br />REC'D BY <br />DATE # <br />VOICE <br />mol;_l <br />C-57 ✓ WC ✓ -WAIVER <br />EHD 29-02-001 <br />6/22/04 <br />C-57 Letter of Authorization to sign permit -41`- -Encroachment doc <br />