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ian Joaquin County <br /> Environmental Health Department � SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 I�IItTtGATION <br /> z , <br /> c ` % (209)468-3449 Fax: (209)468-3433 Web: www.co.sai-i-joaquin.co..iis/ehd ' UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUOJU,�, 10 P4! 4: r� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application►i_sl 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 /> 61091c- <br /> / Assessors <br /> WELL Location f� 61091e- �'+? JT Cross Street L S� City �7d64'-Z1A ZiIp /S Parcel# - <br /> PROPS -, /yam" Q / <br /> Owner U 17�- t .t'3f'r.:' �. \ddress .S/`�/I�' �I L�pI�G77���(�CityS [� _� Zip 7S ---"hone# 71 3 F34(� <br /> C-57 Contractor'i A� t S(�yf Address`1Sy H�w� 121;) Cityrtt Lic#�`)/Phone# �l2r 3/3~�uv <br /> Consultant/Sub Cntr sf7 � ! A&40' d s 937 51� City /- -rr Lic#/P1 Phone# 71*d <br /> GIS Coordinates:X — Y Township Range_ Section <br /> WORK TO BE PERFOR <br /> NEW WELL/ ORI PT�EOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> a SOIL B G# a OVER-BORE. DIAMETER <br /> 0 WELL# PRESSURE GROUT <br /> a*Other `n' GROUT SPECIFICATIONS <br /> COMMENTS:�T &OA&r<� TVy jJ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING a HOLLOW STEM DIA.OF BOREHOLE " Q MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL G PVC O OTHER:_ <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEA.(UZ7�4— TREMIE TYPE TO BE USED: UGERS �1OSE <br /> p AIR SPARGE/OZONE USH POINT(GP cr CP ROUT SEAL PUMPED: )(Yes a No (DOTE: MAXIMUIV! REE- ALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:_G OTHER _ APPROX.BORING DEPTH 2fX� 0' BOLTcD TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED_jl j�) (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING 'HOURS NOTICE REQUIRED FOR INSPECTICNS. <br /> I hereby certify that 1 have prepared this application and that the work wi!I be done in accordance with San Joaquin <br /> County O " ances, u+es aiid Regulations, and all applicable California State Laws.. � /' <br /> Signed x / Title/Company? IF�7 (ire"4- Sr _ <br /> Print Name -*t L � 5��t Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Ld h Date I ed O Area <br /> Grout Inspection By Date Final In ection By D to <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 50 <br /> -9 ,979-00 z.o� j �/ vS R# 3 8 3 5 <br /> C-57 WC WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 9/30/2002 <br />