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Ian Joaquin County <br /> _ Env&mental Health Department <br /> • VIG <br /> f1 D304East Weber Avenue, 3rd Floor, Stockton, CA 95202(209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd � <br /> trFa �P F O <br /> 290 <br /> is " `,,, pMlp .14�1rmitApplication r./ <br /> NON-REFUNDABLE-PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FI; Ir/SFS fHEA!Ty <br /> v� <br /> Application is hereby made to S &>'Joegwn'_County for ai ermit to construct and/or install the work described. This application is made in compliance`with San <br /> Joaquin County Development TNltkyjj a i,'` -��'7 a ft Standards of San Joaquin County Environmental Health Department, <br /> Assessors <br /> WELL Locationx1521 1ti. I•Ju" 14k�- Cross Street 5.)_r4j. `;•,`. City c-i<.+o:1 Zip q5-Ze3 Parcel# <br /> PROPERTY <br /> Owner_ 15„�n Address C'� ag G7lc, City 5•hZip4S7c.Cr Phone# /7e:Q)Rya--'7'7'77 <br /> C-57 Contractor [ ca �t' i�lh ' Address k3zn),,ac. City •' Ar ZiPjS:7YZLic# WjS:le Phone# /g1G)6- -06-1 <br /> Cit run x <br /> Consultant/Sub Cntr Aa� -,�: Address R37 City SFs<kFc.. Lic#/ b2Z^ Phone# %7sk��/�/-IeEC� <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> SEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> p SOJL BORING# 0 OVER-BORE. DIAMETER <br /> E-VTELL# 71ALli-I Zs ^R4�i- fti /a -• yw11a...;tu:r u< � 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> kiONITORING 0 HOLLOW STEM DIA. OF BOREHOLE$_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS St_xy HO TYPE OF CASING: 0 STEEL 9-PGC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL LS /S 3 t TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> 0 AIR SPARQE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ,k Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> O SOIL BORING OHAND AUGER GROUT SPECIFICATIONS Qra.,� <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH C,S' BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED T(O (if YES, list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. / n <br /> Signed x Title/Company _.l <br /> dd - t <br /> Print Name J_>"j Y°1 (�+Gw p✓.,,.,�,�,._ Date ,Z�—,-.�. <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> (z )) <br /> Application Accepted y i Date issued /! 7 7 06 Area <br /> Grout Inspection By Date/ !-3j 0(0 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: i <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> �s°I Li 3b$ 234''! iiz, r SR# �(; p7 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> , ^tU 2v-Vi-Ii0! <br />