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San Joaquin Count <br /> Envie:jimental Health Department <br /> SITE <br /> 304 East Weber Avenue,3rd Floor, Stock-ton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: .sjgov.org/ehd UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR F IOM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or instal 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 /> S�-City <br /> Zip <br /> Assessors , <br /> WELL Location 3 G�i�.-. ti Cross Street 5r ural Ci Y-a c ���+, q-520-5q-520-5q-520-5Parcearcel# 1 UV <br /> PROPERTY S•r(g G Tom` V [A h <br /> Owner A Qr %hL'tg ' ParriwrAddep <br /> � ,"L C., Zip y 5205Phone# <br /> C-57 Contractor C-fG�G, Dri I/,~� Address <br /> �9J lfo c jedA-t I CtyM& I <F Zip_2 'Lic# YNSAS'Phone# `l 33-5 9Cv <br /> Consultant I Sub CnVCe..�rLS r"'.srr4."1+I Ir <br /> Ad dre s2-10 Vetko T6{,� Lic# Phone#- 6 -4.35 2369 <br /> GIS Coordinates.X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, THER') 17 DESTRUCTION (choose type below) <br /> [l SOIL BORING# a OVER-BORE. DIAMETER <br /> 0 WELL# a PRESSURE GROUT <br /> Q"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICA ONS rr <br /> MONITORING AHOLLOW STEM DIA.OF BOREHOLE �r�r ©I AULTIPLE CASINGS ©MULTI-LEVEL WELL CASING DIA: Z <br /> p EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS & O TYPE OF CASING: a STEEL A PVC [I OTHER: <br /> []VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL- r TREMIE TYPE TO BE USED: AUGERS Q HOSE <br /> AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: *Ye5 n No NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> []SOIL BORING p HAND AUGER GROUT SPECIFICATIONS orf(4 ,- J <br /> OTHER: a OTHER APPROX.BORING DEPTH 56 r BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED— 100 (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGR EMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUI ED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the w rk will be done in accordance with San Joaquin <br /> County O +nances, R Regulations,and all applicable Cal ornia State Laws. <br /> Signed x Title/Com any V,Y. C—_0 z:CF_-ILL-Ik- <br /> Print Name if31102Ac- S Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By L ate Issued C ���`T Area <br /> Grout Inspection By Date_ mal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS- <br /> ACCOUNTING <br /> �" �� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3 0 _Z10 SR# <br /> C-57 WC -WAIVER-- C-57 Letter of Authorga#to sign permit Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/30/2003 <br />