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oP4 ••"•.'� San Joaquin County <br /> �: •off <br /> NMI 1.kArinmental Health Department SITE <br /> �04 Ea <br /> sl{W�b9c Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> \c J E.IdVI"(2d54$a3449,,Vax: (209)468-3433 Web: wwwsjgov.org/ehd 11 N IT IV <br /> !lNel�r <br /> - Permit Application ---- <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 /> c� Assessors <br /> WELL Location \b0`O �u��q,,,-�¢,,-.(.., Cross Street 1�� City f� c Zip `5 37 b Parcel# (p <br /> J� <br /> PROPERTY <br /> owner W\A:% e-CC,"r S WN Address\bO--") Du`�\�q r�CityI f'g Z{p S.3.1(.Phone# <br /> C-57 Contractor G —Q AddresscSO CiIIYW!1ar.J.,A,. %i Zip9gSS3 uc#q 2516 phone# �Zt S a)3 S&O® <br /> Consultant/r�cncry��O�•CASL�J— ''6 (b Address �\O\ fir-` St CiN rr-4k 13 LIc# "— Phone# 2V9 $7,L`JI)\91 <br /> GIS Coordinates:X ,Y ,Township - Range Section <br /> WORK TO BE PERFORMED: <br /> U NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DE RU C.TION (choose type below) <br /> 4 SOIL BORING# a SS 0 OVER- ORE. DIAMETER <br /> O WELL# - - - a PRESSU GROUT - <br /> O'Other GROUT SPE (CATIONS <br /> COMMENTS: - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Bast w O cYPIA'•�' <br /> U MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: aSTEEL O PVC U OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 8 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or U STOVE PIPE <br /> C n YICONDUCTOR Cin�ING P\ROP�OI SED (it YES,list ecifoations in comment section) <br /> COMMENTS: 1.�C�gs� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinan RIs tions, and all applicable California State Laws. r <br /> Signed x _ '�� Title/Companyqpa�� a <br /> 1orta /�/WB,40,eg' <br /> Prnl t lay-n F Date <br /> DEPAR T a GENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 23 A!�q 04 .f Ad de-feJ Dee dr( <br /> Application Accepted By--No e-t 4- gI �e wv\ Date Issued t=/zy�OY Area 1450 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3So� S B9 °r' D/6595 Civr� ii iB oy SR# 00'0723 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />