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San Joaquin County COPY <br /> REC(��(� �03�ITE <br /> Environmental Health Department I� V 7 <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> m �4 NOV 1 4 2005 <br /> (209)468-3449 Fax: (209) 468-3433 Web: vvww.co.san-joaquin.ca.us/ehd UNIT IV <br /> ENVIRONMENT H <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEERMIT/SERVICES <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 /> wisr Assessors <br /> WELL Location /;36-3 A1£7f1A.UY RoA D Cross Street Al f SO City 1U0UA)rAj,0j Zip Parcel#a0 -.L60-Z-2— <br /> //b US <br /> 2//DUS <br /> PROPERTY D - <br /> Owner/AIA RK Cer, AVAR77LS Address 3/20 /RAer Bewz) City IRRA&Y zip 376 Phone#J09-,93e-/5'60 <br /> C-57 Contractor ✓d LU 17RILL/u/- /u4Address l00 CvrrJ Sr1P.0.8eF '-lIL City S L Zip 9s[�/ Lic# BtCOWIPhone# 9/G-���'-'i <br /> p pp '1, 45?'- r;z0904 <br /> 106 <br /> Consultant/Sub Cntr LOAIAOR.LA RrN /LCN./,Aadress IV' /RAA11(. WIfSr e/R.City -"rDCK-r0A)Lic# Phone#,209-e73y-0S/, <br /> Su/rL f. <br /> GIs Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type below) <br /> 0 SOIL BORING# l ^Q.r �1l 0 OVER-BORE. DIAMETER <br /> 0 WELL# v�-�- •J� - PRESSURE GROUT <br /> ^ - <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: £s Y oz£. w-14A� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING p HOLLOW STEM DIA.OF BOREHOLE p MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 7 rr_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL )ePVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING p HAND AUGER GROUT SPECIFICATIONS NLA I <br /> )�bTHER:WATeR 0 OTHER APPROX.BORING DEPTH_ .7,6' 0 BOLTED TRAFFIC BOX or STOVE PIPE <br /> C@UAG7 f y CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: MLU-14A IA1s'r4LL£lS uAJDtR iPx2aIT SRooA116-r2 <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 Ordina as 51a a ulat-ons, and all applicable California�State Laws. <br /> Signed x 'r e/ Title/Company &oyzPAe C.i.efy L66tE S r �a1G <br /> Print NameDate <br /> i i <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS:_ 17/0 ,3? <br /> WORK PLAN DATED: <br /> Application Accepted By Dale Issued <br /> Grout Inspection By Dale Final Inspection By Date <br /> Destruction Inspection By - Date n -i0 6 j <br /> COMMENTS I CONDITIONS: -D ao <br /> ACCOUNTING ONLY: AID# F - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE - PERMIT/SERVICE REQUEST# INVOICE <br /> 2 W58 SR# O <br /> C-57 WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/302002 <br />