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Py <br /> pUIN <br /> San Joaquin County CW <br /> z - z Environmental Health Department <br /> SITE <br /> a <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3444 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 th Standarps of San Joaquin County Environmental Health Department. NGIf <br /> Nc K YIw�►+f� Z SD t yD 1 <br /> •�-- 2 3 775 �•C�r!5enc.� � Assessor <br /> WELL Location Yl� a3�! Cross Street City rYa<- Zip9530Parcel# 3 <br /> S.CMll:SrNuv-�i <br /> PROPERTY <br /> Owner Address '{$S 131 ett i City TyxxcZipql;30Phone#_a29_L1 <br /> C-57 Contractor �Ret'{fv1AA �yp�v rA¢dress a3 S W�' W u- city Zip6ts20�ic#�1�Zb3Phone# 2C'q- <br /> _ 9-71� <br /> Consultant I Sub Cntr Address11a boa City § .�ic#_ CLE g 2- Phone#oto -133 6 -tet i 1� <br /> GIS Coordinates: 111°-215 5,#a vJ Y 3 °�? N' a7.S N ,Township Range—P. S!- Section oG <br /> la1°at' 5 7"vJ <br /> WORK TO BE PE FORMED: <br /> ! NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> j WELL# 1'4xAj-1'7 . p PRESSURE GROUT <br /> 0`Other -GROUT SPECIFICATIONS <br /> COMMENTS: 2-e- a �AG <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,J <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE +r 0 MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA:_a _ <br /> Q EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS 0.1 " TYPE OF CASING: 0 STEEL §PVC 0 OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_„ I g+ TREMIE TYPE TO BE USED: GAUGERS V HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 34') <br /> p SOIL BORING p HAND AUGER GROUT SPECIFICATIONS - ba.Fmµ w ✓ Ccvv�✓� <br /> 0 OTHER: 0 OTHER APPROX.BORING DI TED TRAFFIC BOX or 0 STOVE PIPE WAY <br /> CONDUCTOR CASING PROPOSED noYIe (if YES,list specifications in comment section) <br /> COMMENTS: cS2e � ''1^ ula <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I ave prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances,jtule and Regulations, and all applicable California State Laws. C,.,+e'-1, <br /> Signed x Title/Company- c <br /> L.o <br /> Print Name W c< Date S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 73� W St /r& <br /> WORK PLAN DATED:`` 2-6L 'D 3 <br /> Application Accepted By_ 11WL.( Date Issued_ Lyf I It Id Area <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 /> 3501 MU) T9-&j Z!579 COre- oy t5 o S R# p o i 76 5 A <br /> C-57_ WCC WAIVER_ C-57 Letter of Authorization to Sign permit^Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/30/2002 <br />