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o COVOSan Joaquin County <br /> Environmental Health Department SITE <br /> IERI�M,! <br /> JAtJ 0 40MUst Main Street, Stockton, CA 95202-3029 MITIGATION <br /> . NV1R0f t�6AE 'ax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> ENI- `/!ELRwt1T,;//S1~;�V"CEIVell Permit Application <br /> I, ��`R\•CEc <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 /> 1 Assessors <br /> WELL Location ) y 5 5 J o.L ks d� A-,e Cross Street 3rd Sf• City E S ca i n-\ Zip q-53'20 Parcel#ZZ}-15'q—a49 <br /> PROPERTY <br /> Owner V`G k� ll/te ��b Address Q 0• Q 0-21- o b City E S c u �" Zip q S3Z o Phone# <br /> C-57 Contractor V*W u'-)11%r q Address P.O. Q O)( 17 O CityL D d; Zip952 y Lic#7 Zo gyyPhone# <br /> Consultant/Sub Cntr (.r r �erg Address 171t M c%'. S-F. City LfLq/CA�_Lic# Phone# T-?,- <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> "EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> $,SOIL BORING# H P 1 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING jrHOLLOW STEM DIA.OF BOREHOLE rd" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: N11 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS A)A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL O- -j D ' TREMIE TYPE TO BE USED: jPAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: A.Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS N24 ct—tni- () r�✓ } <br /> 0 OTHER: []OTHER APPROX.BORING DEPTH D ' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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. <br /> Signed x --f— Title/Company S fa F F (!'eo�o y /S 1L /(ri o N o! Z E ro <br /> Print Name J°e- vO1S Date 1 3� O g' <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: IKSs <br /> WORK PLAN DATED 1 10-; 12 13 Io 7 R to&-r-n' .Arf <br /> Application Accepted By Date Issued I / SIP ar Area <br /> Grout Inspection By LA sd- Date 1 l y O T- Final Inspection By Date 1 It <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> zqo( _j$'r69-Vo 017s3`( A,( Il8/og SR# 5 3 d 9 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit-.,--Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />