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PROPERTY Owner (2.(Skik <br />C-57 Contractor Gfe 7 4-1\11 <br />Consultant / Sub Contractor <br />Ad ress <br />Address locio (-,604644- City <br />A <br />Zip 9 c.? Y2-Phone# <br />9 50-Ampt /--)ue city iviez ziP5Lic#6.stV64one# <br />) _ _ s,svc1 _ <br />Address (43-7 5V/0.{A-' r-01' City “ Lic#48027 Phone# <br />-5))/ <br />(MS) 5) 3 ,5-06 ) <br />467 lOX <br />WORK PLAN DATED: <br />Area <br />Date Date Z-7 <br />Date <br />.Ad- govi <br />Date Issued ,-.)"/ '/ /' <br />Final Inspection By <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />NECE VE <br /> <br />WERPERMIT APPLICATION FORivi <br />FEB 15 2002 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />ENVIRONMENT HEALTH304 E. Weber, Third Floor, Stockton, CA, 95202 <br />PERMIT/SERVICES (209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 Joaquin County <br />Development Title, Chapter 9-1115.3 and the Standards 5f San Joaquin County Environmental Health Department. <br />ii P Assessors <br />WELL Location 0-1 O lik-,t51- '1U( VI eri Pal. Cross Street City Zip Parcel# <br />GIS Coordinates: X Y , Township <br />V;g1frK TO BE PERFORMED: <br />EW WELL! BORING ( CPT, GEOPROBE, HYDROPUNgo, HAND-AUGER, OTHER') <br />XSOIL BORING # <br />WELL # <br />Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE c) \ t , MULTIPLE CASINGS? 0 YES 0 WELL CASING DIA' <br />0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS AP-A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL f\---\;kft TREMIE TYPE TO BE USED: 0 AUGERS f 'HOSE <br />0 AIR SPARGE APUSH POINT GROUT SEAL PUMPED: X(es p No (NOTE: TAXIMUM FREE-FALL DEPpi IS 30') <br />1SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Gi(f I (r) VDr\-\00 46 6 74 #10Y7 S CA)c'tC1 <br />0 OTHER: fl OTHER APPROX. BORING DEPTH 1,4915-0 ' BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> <br />Range Section <br /> <br />*Other: <br />a DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br />tions, and aJj applicable California State Laws. <br />Title/Company 6POI ('),/ 5F )4G-E <br />1 r‘ /1110,r-‘ Date DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />Rules and Regu <br />Signed x <br />Print Name <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PER i -- • ---.;• - - # INVOICE <br />---)_,--' <br />tfyl 2-/ k il 0-2 SR# 00,2-31 i <br />C-57 <br /> <br />WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc 25/02