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San Joaquin County <br /> 2 :Z Environmental Health Department SITE <br /> Q <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> •,c '.. (209)468-3449 Fax: (209)468-3433 Web: www.co.san-joaquin.ca.us/ehd UNIT IV <br /> a�rFOR� <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 A <br /> WELL Location � Z-7r� !� ,'-I�+fR f f' Cross Street Ce�fc✓ f,' ssessors <br /> City �FO�Zip ���Z Parcel#/S7-0 <br /> PROPERTY / ' / <br /> Owner C��J�Qd S;�v� Address/4'�� W//, f Zip QJ"7�3 Phone# <br /> C-57Contractor Y,`roweX Address_ //��4a-71J AC CityAew -o Zip9YI-7 Lic#�f/�7Phone# hyo-�Q— 676 <br /> /&C7 ?t Hv lWe-j -Cj rc <br /> Consultant/Sub Cntr Co.-7,,1 Address C-; Fc _7- City•,((--f,-..,Lic# Phone# �oS�-239-=✓'/�3 <br /> GIS Coordinates:X X33 3`1 Y .''(-7(70 Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WrLL/BORING (CPTrGEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> II`` ,SOIL BORING# (� 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 0 HOLLOW STEM DIA.OF BOREHOLEa'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 /> a AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yeas` )(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS !y C � C�• 'LT <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH / S'/ 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 Ordinan , Rules a d Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print NameDate Zs <br /> DEPARTMENT U5E ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: /n �n <br /> Application Accepted By Date Issued v �w Area <br /> Grout Inspection By Date Final Inspection By a✓L Date 0 <br /> Destruction Inspection By ate <br /> COMMENTS/CONDITIONS: O <br /> ACCOUNTING ONLY: AID# s Coti,KTR <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R C' Y DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2g0lZg32 o SR# 3 I <br /> C-57_ WC_-WAIVER_ C-57 Letter of Autho I s 9n permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/30/2002 <br />