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San Joaquin County <br /> z- -� z Environmental Health Department <br /> stockton,CA 952az MITIGATION <br /> 304 East Weber Avenue,3rd Floor, <br /> . ,. <br /> (209)468-3449 Fax: (209)468-3433 Web:www.co.san-joaquin.ca.us/ehd UNIT IV <br /> o <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 /> #, ru,w,�A_,,,� 1 S a t w,1 li+L_5� Assessors <br /> ��i.-e L 7055'309 Parcel# <br /> WELL Location�_„ . __Cross Street G�v vS W"w- City <br /> PROPERTY Lvoncy 4,332 Sr++olc yel{��sC;e 16-0-A 952 t 9 Carrit cws n1Grk hffit�a+{ <br /> Owner Address <br /> Zips Phone# <br /> G-57 Contractor ec vw dress 3� �a� City �N ZipjS �Lic# 1��bhone# <br /> _ <br /> Consultant!Sub Cntr s Ort 3�3 III <br /> w\ C-LJ . Address�a� �l w4sa City�p��.� Lic# � S� Phone# Si _- <br /> G15 Coordinates:X l al' ' SS 3-70'4 r 24•�a ro ownship M Q S. Range �_ S� Section <br /> WORK TO BE PERFORMED: <br /> O NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) D DESTRUCTION (choose type below) <br /> D SOIL BORING# D OVER-BORE. DIAMETER <br /> (WELL# hAW -}�ITb './�1{w�Q-�I13�'� a PRESSURE GROUT <br /> D*Other GROUT SPECIFICATIONS <br /> COMMENTS: f'�C eA-&-C In — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTIONS CIFICATIONS <br /> j MONITORING I)I HOLLOW STEM DIA.OF BOREHOL 81" D MULTIPLE CASIN S D MULTI-LEVEL WELL CASING DIA: <br /> � � bq 4,i.Sr _ <br /> D EXTRACTION AIR HAMMERJDRIVEN CASING THICKNESS D•1 0,1'�''Xp OFC ING: D STEEL f PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL t-kA" __TREMIE TYPE TO BE USED: D AUGERS I HOSE <br /> D AIR SPARGE!OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER: D OTHER APPROX.BORING DEPTH a V, A BOLTED TRAFFIC BOX or D STOVE PIPE of <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: �p — r✓ -���� c <br /> ' f <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 work will be done in accordance with San Joaquin <br /> County Ordinances, Rules d Regulatio s, and all applicable California State Laws. ��� � `��r� <br /> Signed x Title/Company <br /> Print Name Date 3 (g C <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7500 W <br /> WORK PLAN DATED: <br /> Application Accepted By Ayt "��?A6t QOM _ ,_,_,Date Issued DI J4I by Area <br /> Grout Inspection By Date f=inal Inspection By Date 111 <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 350r MW89•°L 279 Cu�,Z cq tsay sR 4037655 <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 />