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San Joaquin County ii r onnIIIFY <br /> EnvirL�Amental Health Department W ECM)Rft <br /> 1_ <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION CP/ <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd LAY 1 ? 2005UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONVE <br /> PERMIT/SERVICES <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.Assess �/ r <br /> WELL Locatioon Y 7 O G' 0� Cross Street _. Ci !!��� �� P 9�— arcel# !P -G 0.03 <br /> ty 7mcIC Zi Pame#F / .? <br /> PROPERTY D'591&- 0-ya Watl_I LLC- 14 <br /> 1� <br /> Owner L/a s�.o4-k T. Q2�cLAh\4 Address 2�O'�r.FY'ZN�oVfl/'�St�/ SuiCity $�+vclC}dYl Zip gSloS Phone# <br /> C-57 Contractor Gr-rA -r1, S .T l'4 Address ` TP [60ct�()t. CityV 'HC Z1p9Y5Li1# `qo�hone# CYz-.S� X13—,SQlcb <br /> Consultant/Sub Cntr6myt6ei!n �myi(o"wtyViAddress 2_tO Pe;Xf"s tf citykCX2j9MaoLLic# Phone# (9a�-) <br /> GIS Coordinates:X ,Y ,Township l 1_1 Range Ca I_ Section_L__ <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING 6LPVGEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> OIL BORING# S t3 -2.10 d >6 2:7 p OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: tLato "�• Sif Gam^ Qd ti/k//�'�l 1i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> B MONITORING o HOLLOW STEM DIA.OF BOREHOLE _V' l]MULTIPLE CASINGS 0 "A�MULTI-LEVEL WELL CASING DIA:"- <br /> a EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS N TYPE OF CASING: B STEEL 0 PVC BOTHER: s <br /> O VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: B AU y~ 0Off� <br /> a AIR SPARGE/OZONE J!"USH POINT(GP or CPT)GROUT SEAL PUMPED: Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> �OIL BORING p HAND AUGER GROUT SPECIFICATIONS_ (jtM Ate: Q� <br /> THER: fl OTHER APPROX.BORING DEPTH___15!ga BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 8 (if YES,list specifications in comment section) <br /> COMMENTS: <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 Ordinance Rules and Regulations, and all applicable California State Laws. �r �J q IN S 1 t7ti <br /> Signed x._� Thle/Company�y L201 �lSyl/-�V J Jam _ <br /> Print NamDate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: � E-_ <br /> WORK PLAN DATED: O p <br /> Application Accepted By Date Issued i!/ ds 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 AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> /� // SR# 0 <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit Encr chment doc_ <br /> EHD 29-02-001 C'S, rL� <br /> 9/302003 <br />