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. San Joaquin CountY <br /> Envie:-pmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: .sjgov.org/ehd UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> r // Assessors <br /> WELL Location 1313 &* C ���. L✓�,, Cross Street t r �L f City o!P44 . Zip Parcel# <br /> PROPERTYj4-1;-Awf%a lak°I <br /> Owner ftnl,a� IVASS,t A1!7arfh Address Z!1 E.Cc�'hv 81�� Ciry Zip 752 Y-0 Phone# zo'-?--q83-bl5 Y <br /> [S 7 <br /> C-57 ContractorZ W M"ll ..a � �Address ISIXWO Ax..c 4-e ci M.sr 14E Zip 9YW Lic#YA5/ Phone# 125-3(3-!;-]Coo <br /> Consultant 1 Sub Cntr Ca4nk�nv.ro�vK.nfsJt « d�ress-�-70 ?°G��i f� Gity �. Lic# Phone#70 - -Z 6 f <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL 1 BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,C THER') n DESTRUCTION (choose type below) <br /> a SOIL BORING# Q OVER-BORE. DIAMETER <br /> SWELL# _M t -6 1]PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATf NS <br /> MONITORING KHOLLOW STEM DIA.OF BOREHOLE_2L�t 1]K ULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA-.2 <br /> Q EXTRACTION 1]AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: []STEEL APVC []OTHER: <br /> []VAPOR 13 MUD ROTARY DEPTH OF GROUT SEAL ;?L TREMIE TYPE TO BE USED: XAUGERS ()HOSE <br /> []AIR SPARGE/OZONE 11 PUSH POINT(GP or CPT)GROUT SEAL.PUMPED: XYe �No (NOTE : MAXIMUM FREE-FALL DEPTH IS 30') <br /> fl SOIL BORING 17 HAND AUGER GROUT SPECIFICATIONS 1 Ira.c.� -e J, <br /> Il OTHER: _ 1]OTHER APPROX.BORING DEPTH 549 IrBOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED k-0 (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 certify that i have prepared this application and that the wi irk will be done in accordance with San Joaquin <br /> County Or inances, Rules and Regulations, and all applicable Cali ornia�Spate Laws. <br /> Signed x _ Title/Company V� '. �y G�= 1 L L a L--) <br /> Print Name Date 1'd. <br /> DEPARTMENT US ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: f <br /> Application Accepted B A D 31e,Issued `� Area <br /> Grout Inspection By Date 110 inal k spection By FT Date <br /> Destruction Inspection B/ Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I`SERVICE REQUEST# INVOICE <br /> Zm SR# <br /> C-57 WCC WAIVER C-57 Letter of Author atio t sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 9/3anoa3 <br />