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SELL PERMIT APPLICATION FORM SITE <br /> MAR 2 9 20 SAN JOAQUIN COUNTY MITIGATION <br /> 33NVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> EP�1VIriU �iviEIJI HEHLI fj E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 <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 /> �l y p �^ 05A,� sessors <br /> WELL Location o� Cx� Q� U�ross Street t Zi �0� Parcel# <br /> TY <br /> OwnerOE��esi-c/ogiist ( e(j&ess_9.6 f',K_a_mp CityLO-1 O%LfioZip m o-9-0�hone# <br /> C-57 Contractor V i r� Address 137 5� 0City ipq, C �ic#(,f one# <br /> Consultant/Sub CntrAddress City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: —� <br /> NEV1(WELL/BORING (CPT,GEOPROBE,HYDROPUN HAND-AUGER,OT�fER') p DESTRUCTION (choose type below) <br /> ,`SOIL BORING# ( 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPE IFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_<F'/ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0/AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ^(SOIL BORING HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER: 0 THER APPROX.BORING DEPTH $� 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 Orrdina s, Rules and Reg lati and all applicable California State Laws. (� <br /> Signed x %V�''`��A44 Title/Company <br /> Print Name �'!/�/ //l��'7 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: `1 O O <br /> WORK PLAN DATED: <br /> Application Accepted By c Date Issued � /Q Area_ .2-- <br /> Grout Inspection By ate Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: fit f'tdL�_ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 17e '�?Ol sR# 3� c7 5 0 <br /> rrC-57_ {{WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc 9/30/02 <br /> /yl-lAt <br /> � --fi >✓ T-� <br />