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FILE COPY <br /> hlv' t;;�'t�B f AL HEAWELL PERMIT APPLICATION FORM SITE <br /> ,7f MiT SF[�VICE SAN JOAQUIN COUNTY MITIGATION <br /> 03 OCT I 0 PM 4� AFF,NVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 04 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ARO— <br /> � (209) 468-3449 <br /> L 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 /> ,t{ y�� r ' �crw Assessors ,�7 <br /> WELL Location m tisCcS-i' 0>v I' y� Cross Street pwSe- city_4�- N o,6 Zip 17Parcel# ��—OrO—0d <br /> wnerOM& L 6D�QnaMSAddress312 Ir0.cV�dY1l)PROPYScity 1 02tc V Zip_ID hon//e# ��OOt� 56 <br /> C-57 Contractor @LV.�-)/1)l l ( Address 3D I I Uv t,Y\ (,M S City (� Zip S ic#0`l Phone#d 31 66 2 P)4,S <br /> / Sk2( <br /> Consultant/Sub Cntr j A (�.SVGS Address Z C City Lic# Phone#'?Z r-f 2-9 J49&D <br /> GIS Coordinates:X 'Y Township Range 4L Section SL <br /> WORK TO BE PERFORMED: <br /> if NEW V=t-L/BORING (CPT,GEo�ROBE,HYDROPUNCH, HAND-AUGER,OTHER') -AlkoE TRUCTION (choose type below) <br /> SOIL BORING# 45-Iq I3r,rf 0 OVER-BORE. DIAMETER <br /> 0 WELL# 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 BOREHOLE 0 MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPT IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIO S offer <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 3n, 0 BOLTED TRAFFIC BOX or O 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 h ve repared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina c le an egulations, and all applicable California State Laws. <br /> d x 1y �I Title/Company <br /> SigneSn/> �)2 <br /> Print Name 1�l L ��I 1 `V�� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: C w(—/" "' rT 0" E C ✓ °u <br /> WORK PLAN DATED: ID—Q-3 <br /> Application Accepted By Date Issued `�—/V'— Area " <br /> Grout Inspection By Date Final Inspection By 4 e Date 3 <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 /> Z-Ro I Z6 p, 10 SR# 35 6 35 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/30/02 <br />