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San Joaquin County <br />Environmental Health Department <br />X34&st Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />Vjp,0P#_qj PL,�09 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />PERMIT/SERVICES Almll Dnrr"i+ <br />MINIM ffm <br />SITE <br />MITIGATION <br />UNIT IV <br />ACCOUNTING ONLY: <br />AID# <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 mad compliance with San <br />FEE INFO <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, <br />REC'D BYff <br />WELL Location _ 27 33 Coukt{ c,y 1 ub P51 vJ (_, , S Assessors <br />Cross Street �c� P � City {r�ck{o�, Zip 95 Parcel# / 30 O/ <br />P <br />PROPERTY <br />Owner Vafmv,, Addressl`(19 Gnxk6 CaKnl Glue( City 55foeAftN Zip +r'5 - A07 Phone# <br />C-57 Contractor(egr,1�/,Il' Kc, Address .2 -1 75- rlvc CityS?y"'i/lf:fl Zip 90806 Lic# G5(`w-lPhone# bt-'/97-68y9 <br />J <br />12 kKL.Ie� <br />Consultant/ Sub CntrS C=tO jz Address -SO' 7 K -kq t)ce 0+`4100 CityC-) 'noun Lic# Phone# q16 ` S?b7 - 0'1490 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />VNEW ELL / B I ((VP, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0-P Z_ <br />OIL BORING # F_ <br />0 OVER -BORE, DIAMETER <br />WELL #_ N leenorJ LUG I�=' (1, PRESSURE <br />GROUT <br />'Other �1� GROUT SPECIFICATIONS <br />--� <br />COMME TS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING a HOLLOW STEM DIA. OF BOREHOLE Z S 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: o STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 110 f C TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br />0 AIR SPARGE/ OZONE PUSH POINT (3Par, )GROUT SEAL PUMPED: ,®'Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER( /�/�, I�1 GROUT SPECIFICATIONS VPS t G N we en7 <br />OTHER: t, iV \P��(����t 1��Cpp�^{] OTHER APPROX. BORING DEPTH Ito ft 0 BOLTED TRAFFIC BOX or O STOVE PIPE <br />w�.c� "rU 7 f_' fr CONDUCTOR CASING PROPOSED lc, (if YES, list specifications in comment section) <br />�'P " <br />b_ <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />43 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 x i. - Title/Company <br />Print Name s f .' _ Date Z' Z z J 5 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: a -S <br />- v <br />WORK PLAN DATED:CV <br />Application Accepted By Date Issued Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED CHECK # <br />REC'D BYff <br />TE <br />P <br />INVOICE <br />r <br />� <br />C-57 1 WC v -WAIVER_ C-57 Letter of Authorization to sign permit_ Enc doc=vim <br />EHD 29-02-001 4 ae.,c H _ <br />6/22/04 <br />