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r-11 r <br /> pnpy <br /> pQV�N n Joaquin County <br /> $ITE <br /> Environmental Health Department <br /> { <br /> N: 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.co.san-joaquin.ca.us/ebd UNIT IV <br /> CgLlFOR�;,P <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 /> Joa uin County Deve pment Tit,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ✓l.��^rAssessors fd'L"C-Ci <br /> WELL Location. 4:1)( b r' IL�GG�'`� /�'"-' Cross Street /�ity ip �� Parcel# wt������ ��' <br /> i <br /> PROPER <br /> Owner r Address/ 7rr /Ic-Ci Zip / ) Phone# <br /> µrwv 4L <br /> G� City Zip� Lic hone# <br /> C-57 Contractor ��:ti Address ty L 11 l <br /> Consultant/Sub Cntr <br /> )� Address C T f / �`itY �I�A �ic# Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> W �TOPERFORMED: <br /> NL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# _ 0 PRESSURE GROUT <br /> 'itGROUT SPECIFICATIONS <br /> 'a-Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: STEEL PVC 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 /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: <br /> R�j- Ata,-' It <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify at prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin c es and Regulations, and all applicable California Stat Law . <br /> Title/Company <br /> Signed x <br /> Dat <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date Issued C Area v <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: — <br /> LCTING ONLY: AID# FAC# <br /> S FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 0 ��'� q'1Z SR# Q y� <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/30/2002 <br />