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a Gan Joaquin County <br /> °U E %4% g fttental Health Department • SITE <br /> { 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> D�(1 )04j8,ZI Fax: (209)468-3433 Web: www.sigov.org/ehd LJ I IV <br /> ``FQ ENVIROWENT HMIRI Permit Application FILL <br /> PERM-MAMLE 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 /> �( CC'�- 11 ��� /�"� Assessors l <br /> WELL Location��,a .TYor'bkg0 lL _. _Cross Street'TnLV-- 4AA _ City Zip_. .1.126-'/ . ..Parcel#"LJ-6Z:7-0+1 <br /> �I G 1 Z41–bZ -oo 9 <br /> PROPER a �'3g '1 ror"AgQ- , City ovL Zip�Phone#* '� <br /> Owner Lr• Address d hc9 ) .54T -,7 4? <br /> C-57 Contractor Address il5b TT�u h,p. City _Zip�Lic#ykr&� P_hone#91.f <br /> Consultant/Sub Cntr Address:ft/G. t/,r.,ry,.t Kel, City P/roses„ t Lic# / Phone#(1,?P 94/Y­2fc'J Y <br /> i/ <br /> GIS Coordinates:X 'Y Township a 5 Range _Section 4 <br /> WORK TO BE PERFORMED: <br /> NEW WELL I BORING (CPT,Gf.00;ROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> SOIL BORING# PPE u OVER-BORE. DIAMETER <br /> WELL#_ S O PRESSURE GROUT <br /> Q <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �O .D-7 <br /> MONITORING a HOLLOW STEM DIA.OF BOREHOLE n L PLE CASINGS O MULTI-LEVEL WELL CASING DIA: _ <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS r�r.. qQ TYPE OF CASING: a STEEL a PVC a OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL /r r TREMIE TYPE TO BE USED: D AUGERS O HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: yYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS P44/ d <br /> g OTHER:_G OTHER APPROX.BORING DEPTH `/O a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED IJO (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 /> 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 and Regulations, and all applicable California State Laws. I <br /> Signed z11 Y/l Title/Company 7 C-/Do r- T <br /> Print Name�Yl" TPw Jr R..QQ Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 932. S ST RT 99 F FR oAJT Pr•E RD <br /> WORK PLAN DATED: topv 5 2 DU'I <br /> Application Accepted By V j r f0 r i a 111 p !�f r 4�14 Date Issued /a -I n 'U r7 Area <br /> Grout Inspection By ✓'.4ai+ie )_llt.lr/lr Date / -9-07a Inspection Byyi r+ar'irx.L. Y)lc.e4r�'na.pate G -/O -OB <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: J <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE=CODES INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVd10E <br /> 19gvv ? 383. Ov 308 �1 0 L~ /1 /o 07 SR# 00 5'? <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB <br />