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z �1 "an Joaquin County E" <br />' P�u-•"-•.0 'r SATE <br /> ,a e, artment JAN <br /> - - _ rTironmental Heal#h Dep , p z0a4 MITIGATION- <br /> En <br /> �' �' Weber Avenue, 3rd Floor, Stockton,CA g <br /> 202 2 UNIT.IV <br /> ai, < 304 East l �� JT <br /> HEALTH <br /> 209 458-3433 Web: www.co.san-joaau <br /> (209)468-3449 Fax: ( ) � �jj/SERV <br /> ICE <br /> 4 1� / <br /> ES i YEAR FROM DATE155UED <br /> NON-REFUNDABLE PERMIT EXPIR1 {' <br /> is hereby made to San Joaquin County for a permit to construct and/ori stall the County described. <br /> isHealth <br /> plDepon i <br /> rlmentade in compliance with San E <br />{ Application Y ' <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of•San 4 i�•- Assessors I <br /> [aD7 S, rflfa �S c�L 'I zip9S�06 Parcel# /y�� �z/y-V <br /> WELL Location Cross Street I c�ISS n SC Y i <br /> f PROPERTY �J ,,n p Ci J �� Zip X06 Phone#20 21 <br /> Owner L Yu `n eel „ ddress !/' Q�� A <br /> Zipgysl Lic# O JPhoneg Gp <br /> C-57 Contractor �r�� Address it D•EE�X � City Y — <br /> 12G''n4�0;h Phone# - s <br /> Oe /fL CityC o rd_�y <br /> Consultant/Sub Cntr 4J - e <br /> Address f 3 O �- �Uc#-- -- <br /> r Y <br /> �i Range', Section <br /> GIS Coordinates:X Township <br /> WORK TO BE PERFORMED: E'S <br /> I TRUCTION (choose type below) <br /> p NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') :;1 OVER-SORE. DIAMETER,_ 1 - <br /> p SOIL BORING# a PRESSURE GROUT <br /> p WELL# GROUT SPECIFICATIONS_ <br /> O'Other <br /> COMMENTS: �� ✓ rc <br /> 3 ; <br /> TYPE pF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING d HOLLOW STEM DIA-OF BOREHOLE �MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA <br /> a EXTRACTION IJ AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL 0 PVC D OTHER: <br /> g VAPOR p MUD ROTARY DEPTH OF GROUT SEAL, 11 TREMIE TYPE 70 BE USED: Q AUGERS j]HOSE 1 <br /> 0 AIR SPARGE/OZONE ©PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3Q') <br /> U SOIL BORING ©HAND AUGER GROUT SPECIFICATIONS �j <br /> 0 OTHER: <br /> OTHER APPROX.BORING DEPTH BOLTED TRAFFIC SOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 'i (if YES,list specifications in comment section) <br /> li I <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, a II applicable California tate Laws. <br /> Title/Company <br /> Signed <br /> Print Name 1 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: r/I ' <br /> WORK PLAN DATED: 3 D3 <br /> L I h ` Dale Issu Ind ZZ Area u" <br /> Application Accepted By. �^"-{tip <br /> Grout Inspection By �( � ^r u F Date if 0 Final Inspection By <br /> Date � O <br /> Destruction Inspection By <br /> Date <br /> COMMENTS/CONDITIONS: 31 :21 44i <br /> ACCOUNTiNG ONLY: AID# FAC» ! <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE; PERMIT I SERVICE REQUEST.# INVOICE <br /> 3 <br /> -0 Z- ,�ot00 1 3 - ', o� 'sR# <br /> C-57WC� WAIVEi2— C-57 Letter of Authorization to sign permit Encroachment do <br /> EHD 29-02-001 <br /> 9r3lanoo2 <br />