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p411" San Joaquin County <br /> e ` Environmental Health Department W� �E <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MIT TION <br /> (209)468-3449 Fax: (209)468-3433 Web: wwvv.co.san-joaquin.ca.us/eWY 1 7 20UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONME '/H�/E�ACLTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This P application is�atltstir%Impliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, <br /> Assessors <br /> WELL LocationJ T Cross Street'-l_ City Zip SJ0 Parcel# <br /> PROPERTY q I G <br /> Owner C 4. 2Address 1 5. MENS City l� Zip/g53}Phone#q ]. <br /> C-57 Contractor_ t^� Address •�. City 0 1 '(- Zip I ,nL.ic# 760 Phone#�-�/ p, 0c�/ cl <br /> Consultant/S r fyl'e1 e r Addres;26Z5 L. Ajr4le City,��Li,# NA- PhonemA �VO-0- 6 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORIN (C GEOPROB DROPU AND-AUGER,OTHER`) p DESTRUCTION <br /> 0 SOIL BORING# (choose type below) <br /> 0 WELL# 0 OVER-BORE. DIAMETER <br /> 0.Other - 0 PRESSURE GROUT 1 <br /> -J 1 GROUT SPECIFICATIONS <br /> ' <br /> COMMENTS: G W an OA q4 / �,tJrr r��t W V',UfF+ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS p HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE' MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING HAND AUGER GROUT SPECIFICATIONS I, <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH1 �2r Q- O 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ) (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 INSPECTIONS. <br /> I hereby cert! t at I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord' a ces :les d Regulations, and all applicable Californ' tate Laws. <br /> Signed x Title/Company /Z! rr-t <br /> Print Name Date ih <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: // C <br /> Application Accepted By 1� Date Issued 5//60-� AreafsA 9 /-7 <br /> Grout Inspection By 4y<m0aDate 20�Final Inspection By Date <br /> Destruction Inspection By Dale <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> t 2 12C) I SR# <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 />