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.,.3an Joaquin County <br /> :a Environmental Health Department ..� SITE <br /> :j 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> MITIGATION <br /> _ ATION <br /> P (209)468-3449 Fax: (209)468-3433 Web: www.co.san joaquin.ca.us/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 /> WELL LocationO 0167- (jA—7—g "r- Cross Street I Wt0L/( CityGIGr-� 9SZ Assessors <br /> ZIP <br /> V� parcel# <br /> PROPERTY CL <br /> - <br /> Owner �tS/ �f Address_* t4sT ct-A <br /> yST c;tyS1�t4r,-1Zuio Zip 1�r�6Pnone# <br /> C-57 Contractor" [idL AciclresslbC8 MI!.42 �80 <br /> � CitY /4 ZiptPLk# 7A/7Phone <br /> 2, <br /> & <br /> *1111/ lss �ACite 6?i 3Z3 <br /> Consultant/Sub Cntr4A—*'k / ten! Lic# V 2 27 Phone# oi; <br /> b <br /> GIS Coordinates:X___,Y ,Townshi <br /> P Range__ /�%-/_ Section <br /> WORK TO BE PERFORMED <br /> p NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-)p SOIL BORING# ESTRUCTION <br /> (choose type Pelow) <br /> 0 WELL# OVER-BORE. DIAMETER_ <br /> a'Other PRESSURE GROUT <br /> GROUT SPECIFICATIONS ( �/� <br /> COMMENTS: S( 'iY �1�i''`f Ln/�� !i✓ELL Atw --10 SC�Ef�( �p' p �� Z I IJ av TEQ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING U HOLLOW STEM DIA.OF BOREHOLE ­T-LEVEL <br /> 0 MULTIPLE CASINGS a MUL WELL CASING DIA: <br /> a EXTRACTION <br /> AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: j]STEEL 0 PVC a OTHER- <br /> 0 VAPOR 9 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: <br /> 0 AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: l]AUGERS 0 HOSE <br /> Q SOIL BORING �Yes l]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q HAND AUGER GRCUT SPECIFICATIONS <br /> a OTHER: a OTHER APPROX.BORING DEPTH <br /> []BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 43 WORKING HOURS NOT!CE 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 /> Countypfdjnance�'Rul an Re ulations, and all applicable California State Laws. <br /> Signed x <br /> ` __Title/Company�.ii�;j <br /> Print Name ��,,�,� � I)OSoM Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By C c c• W :,Date Issued fvfArea <br /> Grout Inspection By Date Finspection By J O (2 7 <br /> Date c� <br /> Destruction Inspection By Date — � <br /> COMMENTS/CONDITIONS: / <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE LPERMIT/SERVICE REQUEST# INVOICE <br /> R# <br /> C-57_ WC--WAIVER— C-57 Letter of Autho z lon o sign permit_ _Encroachment doc <br /> EHD 29-02-001 <br />