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y ur <br /> s° • • o _ San Joaquin County _ <br /> Environmental Health Department SITE <br /> w• < 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 /> L , o Mi <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 /> WELL Location 18 I ! s'• rG EJ/10 ,Cross Street IOwy, Ci 56em" Zi �i (Z rcel#Assessors <br /> CC�� ty p 9JfZ0 Parcel# <br /> PROPE �T1Y' /� `�rw.{'an,. ✓A ley <br /> owner YQJ faaro@S Address 9lMycry S�vek�4su zip "Phone# 'Ta?- 95/ - 7283 <br /> C•57 Contractor r, %O.* Address 01550 jj" R P city, Afie�jEfffozip 9�ic#jffl'5i/OJcPhone# 9Z5- 313 - 5V*,v <br /> Consultant l Sub Cntr Address 2 % City *aLwal,Lic# Phone# 510 03OF7 . 99�3 <br /> GIS Coordinates: X Y , Township Range Section <br /> ORK TO BE PERFORMED: <br /> IEW WELL / BORING (CPT, GEOPR.QBE, HYDROPUNCH, HAND-AUGER, OTHER*) p DESTRUCTION (choose type below) <br /> J SOIL BORING # OR %/ D �52� 0 OVER-BORE. DIAMETER. <br /> r WELL # ='W � / 0 PRESSURE GROUT <br /> �J *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING I HOLLOW STEM DIA. OF BOREHOLES 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA 2�C <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ? PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL E ' +4.f TREMIE TYPE TO BE USED: 0 AUGERS I HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: No (NOTE: M I UM FREE/ -,FALL DEPTH IS 303) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS' " Q�4Pyl M�S%Ut 6 414 <br /> OTHER: J& $ a OTHER APPROX. BORING DEPTH 25 t I BCJI.TED TRAFFIC BOX or 0 STOVE PIPE <br /> Y.n jeot-i r CONDUCTOR CASING PROPOSED S (if YES, list specifications in comment section) <br /> COMMENTS: 26Vt C°o innard + jen.r,7l-� S 70 j�c�. r f�f wtJ4L ( A� *r) <br /> NQTE :--0FFSITE BORING$ REQUIRE ACCESS AGREEMENT OR-EUCBOACHMENT-PERMLTS. <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 O antes, R and Regulations, and all applicable California State/ Law_s. p <br /> Signed x Title/Company ��o/a�9/sl" /C ���CCe -� �zt6k�i <br /> Print am Date ,Y � <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : FS <br /> WORK PLAN DATED: tAed._ Z ( _ 2.00�I <br /> Application Accepted By. r f!= Date Issued '�— / ]�/D Area III <br /> Grout Inspection By Date. Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: co �; TC L .v 1 C <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BYDATE PERMIT I SERVICE REQUEST # INVOICE <br /> SR# 3Z 1 <br /> C-57_ WC.---WAIVER. C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> BUD 29-02-001 <br /> 9/30/2002 <br />