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o sal. San Joaquin County <br /> 0 <br /> Environmental Health Department no SITE <br /> PN <br /> l <br /> y W� N <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> c•: P (209)468-3449 Fax: (209) 468-3433 Web: w-vvvv.co.san-joaquin.ca.us/ehd JUN2 7 UNIT IV <br /> �fFpR 2004 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ENVIRONNiE L�C,�Ir <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described, This app l{dgypp�V'P4n'�Kr� 1Ade with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health bep V_I_C.'[fS. <br /> 5�0 �. ,� �' C1 1 I I `)52 02 Assessor;,,, <br /> ercel4�3 7—Z/O <br /> WELL Location 6tgnO A J/• Cross Street City S'rO�KTOYI Zip <br /> PROPERTY II < /I '/ <br /> Owner CSU Address DO �/eta-'t5k0✓o- Cityip' �ZPhone* 57/02-95)-'/IZO <br /> nr�eNo <br /> C-57 Contractor TE Address 113.50 ll�o.eior �4.k. &e Cit Cer./e VA Zi. ic#_Phone* `!/6-60-80/a <br /> /88 ra k (4)est Cie, <br /> Consultant/Sub Cntr (!�0 vwt0✓' Address S' ;ie r City 54x"A Lic# Phone#209-23'/-05/21 <br /> GIS Coordinates:X ,Y ,Township / No✓f-(' Range (d e&S Section Z- <br /> WORK TO BE PERFORMED: . <br /> 'NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGE OTHE 0 DESTRUCTION (choose type below) <br /> g SOIL BORING# Jcro.+o,1 re tZ 0 OVER-BORE. DIAMETER <br /> a WELL# p PRESSURE GROUT <br /> a*Other . 1 GROUT SPECIFICATIONS <br /> COMMENTS:3J,t miv4t,.2 (Q2Y <br /> a-,J <br /> C <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING p HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ASA .. TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> g VAPOR a MUD ROTARY DEPTH OF GROUT SEAL_TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> g AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING p HAND AUUGGER� GROUT SPECIFICATIONS <br /> 0 OTHER: /' OTHER rir Lw � e� APPROX.BORING DEPTH 25' 0 BOLTED TRAFFIC 80X or 0 STOVE PIPE <br /> CONOUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: l �- + C-C3 0� S� (D <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 Ordin Rules a p Regulations, and all applicable California State Laws. ..y� —r- 1 <br /> Signed Title/Company COtnjo✓ Ea-r 1h I c- Halo W. <br /> Pdnt Name I Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS' '5-16 7'tR-S <br /> WORK PLAN DATED: a <br /> Application Accepted Bytile,. Dale Issued .11 Area s <br /> Grout Inspection By D t �a d Final Inspection By Date <br /> Destruction Inspection By Dale / <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT:RE:MlIEDj CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> b1 1 $moi f Z`l I ( g, G 1 la o SR# 3 95 0 9 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/302002 <br />