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FILE COPY <br /> hNv1[wwEw1XV kPj ERMIT APPLICATION FORM SITE <br /> P�:D .T Q.FRVICE SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 03 JUN 19 �IO£35leber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (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 /> Assessors <br /> WELL <br /> WELL Location T �� __Cross Street s rrR�7 Zip Parcel#.2oq-ol•b -o <br /> PROPEBIY� 1;ff e* / <br /> Owner a-JrHeAddress 3/Wo Tea-C-7 01'­4 City /k-Ccc!, ZipYr-776Phone#:9-4 -I&-T(, <br /> Su-7 <br /> C-57 Contractor V")--++eK Address­71 /4"J/'�Ve- City 4ew.,r&i o Zip f'YJ 2 2 Lic#7o4-lz7 Phone#S70-/Y a -76 74O <br /> /%C WeirG•-c/c <br /> Consultant/Sub Cntr Co..icto✓ Address Sc.l f-a L CitySr'•cur­-+Lic# Phone# ?-9-27`Y-x'/13 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 'NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) n DESTRUCTION (choose type below) <br /> KSOIL BORING# c7 0 OVER-BORE. DIAMETER <br /> 0 WELL# n PRESSURE GROUT <br /> 0'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE.;�" []MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREWE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> XS OIL BORING n HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH 3�/ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Al- _(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 Ordinances, Rules and Regulations, and all applicable California State Laws. / <br /> Signed x n 2d Title/CompanyAfj.-c, tt- <br /> Print Name Cc /'7• Date—6 /'o3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: -' �r</ C om/V <br /> WORK PLAN DATED: Sr�O <br /> Application Accepted By Date Issued 01-3—Area <br /> 3Area D`� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FACCOUNTINGONLY: AID# FAC# <br /> EE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOIC'oo­cl <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/30/02 <br />