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C / <br /> San Joaquin County <br /> r. �s Environmental Health ]Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> 209 468-3449 Fax:(209)468-3433 Web:www.co.san-joaquin.ca.us/ehd UNIT IV <br /> O ,' NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> CS <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 Siandards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location (, L- /� i�'i l�/��"V�"�oss Street City e D. If Zip�arcgl# <br /> tr-Aa/' M C. 0. <br /> PROPERTY/,/ l e„„/ ` i .3 3 3 <br /> Owner_ C i 7 ,/ Address-----------------------CI t/ ty/_/_Zip Phone# 5 `� r�7 <br /> C-57 Contractor M� h/ f!0•1)q Address A 1_3S8 614C <br /> City7-s/�TO•7Zip ��6 ic� 7?o9 7F� 7>) 7/6-0 <br /> Consultant/SubCntr Z` e_/h� a ;QWess/_3SO 6140 City 0SEI1(o -(ic# COQPhone# 916 7ffI? <br /> 3'wt f G 3©O <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED, <br /> --AUEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') B DESTRUCTION (choose type below) <br /> B SOIL BORING# B OVER-BORE. DIAMETER <br /> LL#�"/ 6 C-XT1e4-1 T PRESSURE GROUT <br /> BOther GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t <br /> MONITORING >104OLLOW STEM DIA.OF BOREHOLE B MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS ,6 qb TYPE OF CASING: B STEEL WVC B OTHER: (� <br /> GAPOR MUD ROTARY DEPTH OF GROUT SEAL 301 TREMIE TYPE TO BE USED: B AUGERS B HOSE r <br /> *IR SPARGE/OZONE B PUSH POINT(GP or CPT)GROUT SEAL PUMPED: B Yes n No'(NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS -,Vt=l,T eC-444CV T �. <br /> B OTHER:_0 OTHER APPROX.BORING DEPTH -7C���/b OLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASING PROPOSED AJ AA (if YES,list specifications in comment section) <br /> COMMENTS: ��1� 0 —O I' &C rO A r AW'"'0" P—e ' e2�` � <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. aF <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. i <br /> 1 hereby ertify I have prepa ed this application and that the work will be done in accor e wi San Joaq nC <br /> County di aWcsule an eg ations, and all applicable California Laws. 9"�o'5 S t ✓ <br /> Signed x — - P y heal epi s� /F_Z C e En 1 a{� O•'1 <br /> g Title/Com an <br /> Print Name MjCVcLe'1 f \%- \1W Date CA���b� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> i <br /> Application Accepted By Datelssued �' Area 997 <br /> Grout Inspection By Date r Final Inspection By Date <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: F <br /> PE CODES FEE INFOjAID# <br /> AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 8� 1 bOF SR# �0�) i qS0q— � <br /> r <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 />