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" San Joaquin County <br /> - Baa".. ' ••.co <br /> z <br /> 1 Environmental Health Department SITE <br /> N: <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/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 andlor 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 5-7f til. E rtN r tL Cross Street i��t Y j; �� e� Assessors <br /> _Zip T7 � Parcel# --Z-3 -3o a/ <br /> PROPEl3TY <br /> Owner 5kTtJAH ViNG-t{ Address_ 5A „City Zi <br /> P Phonek-1 - ��3 3 f-/.6 <br /> C-57 Contractor 149"1 fc-r ±: Address Zog ta, FZ�-I?tN��Y71�aCity �{r+4it�t, i {(C1o0n <br /> CC Phone# Z - a^ 2 <br /> Consultant ISub Cntr k SC-( Address SA I-t <br /> C'tyLic# Phone# <br /> 4 = P <br /> GIS Coordinates:X 21 Y5 1 y 1�!°7.L^z.froo Township Z`� Range 9 Section r� <br /> WORF TO BE PERFORMED: <br /> EW WELL!BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION' (choose type below) <br /> 0 SOIL BORING# <br /> a WELL# 0 OVER-BORE. DIAMETER <br /> Others yc hl 6 JS p A— Ci _ 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: "I`4 trk D M� 'Zp pl _rJ G-t J C• L J <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING NIOLLOW STEM DIA.OF BOREHOLE ��' <br /> 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL`' $'PVC 0 OTHER: <br /> gIROR 0 MUD ROTARY DEPTH OF GROUT SEAL. 13 TREMIE TYPE TO BE USED: AUGERS jj HOSE <br /> SPARGE/OZONE 0 PUSH POINT(GP orCPT)GROUT SEAL PUMPED; 0 Yes po (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING HAND AUGER GROUT SPECIFICATIONS y <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 1 -i-BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED o (if YES,list specifications in comment section) <br /> COMMENTS: P B. b � �t f�G-(+J - 4J LL 0-C <br /> i <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. ; <br /> Signed x �- an Title/Com <br /> P Y Q moi- P✓ri.G-s—i c..C^. �s^1.�.�rl�-/.-.+-�,J` <br /> Print Name Date _001 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE,ADDRESS: <br /> WORK PLAN DATED: J,{ <br /> Application Accepted By ' ^�"'f -' „Date IssuedO Are <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date (. <br /> COMMENTS I CONDITIONS: r <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D'BYDATE PERMIT!SERVICE REQUEST# INVOICE <br /> SR#00:1 � <br /> C-57^ WC--WAIVER C-57 Letter of Authorization to sign permit—Encroachment doc� <br /> EHD 29-02-001 <br /> 9/3012003 <br /> 1 <br />