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SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />2? zed-- Area <br /> <br />Date <br /> <br />Date Issued <br />Date , Final Inspection By <br />Date <br />SITE <br />MITIGATION <br />1005 UHANYIT201V pm 12: <br /> 26 <br />SAN JOAQUIN COUNTY <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mAcp L <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Departmenfl ALIY DEPARTMENT <br />'1 (HD Pervalbyt Ave- City 414-hift. Zip4t6i-0 Phone# <br />C-57 Contractor 1,k, MAW Dr vi Address To v-Vte_ City 6Afelik Zip 15C1)3 Lic# 0107 Phone# (701)41/41eItIO <br />City Stwiink Lidt Phone# 47-thbi„ <br />GIS Coordinates: X <br /> <br /> Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />)11,EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) I] DESTRUCTION (choose type below) <br />SOIL BORING # fl OVER-BORE. DIAMETER <br />XWELL # J PRESSURE GROUT <br />fl *Other GROUT SPECIFICATIONS <br />COMMENTS' <br />it. 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 />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> <br />_ <br />WELL Location Ct ZaFroS kailaCross Street ../!)111644r 4 City Aellikr Zip q5a) Parcel* <br />Assessors <br />Owner s"-0%.ik , co vy, Address <br />PROPERTY <br />Consultant / Sub Cntr A-cle <br /> <br />Address 3."1 Stuttp <br /> <br />INSTALLATION TYPE <br />IKIOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />fl MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE T' 0 MULTIPLE CASINGS a MULTI-LEVEL ,WELL CASING DIA: -7--!•-f <br />CASING THICKNESS Scl, lo TYPE OF CASING: U STEEL )PVC U OTHER: <br />DEPTH OF GROUT SEAL 10 TREMIE TYPE TO BE USED: 1:l AUGERS ,11(1OSE <br />OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS PO (+I &kJ <br />a OTHER APPROX. BORING DEPTH A-cip t lietiOLTED TRAFFIC BOX or 1:1 STOVE PIPE <br />CONDUCTOR CASING PROPOSED tex D (if YES, list specifications in comment section) <br />TYPE OF WELL <br />MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE/ <br />0 SOIL BORING <br />0 OTHER: <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 x Title/Company Sitter WC/ Clekkviroioatuld <br />Print Name &A 'VAC_ L, Date Dc)" VS <br />DEPARTMENT USE ONLY <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />_ <br />I 6Re90 MVO <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC' BY DATE , PER — - r• • # INVOICE <br />.350 31s 00 z'2 -zt.z SR# <br />C-57 WC -WAIVER C-57 Letter of Author&il <br />• <br />o sign permit Encroachment doc <br />EHD 29-02-001 <br />6/22/04