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*Ad `I <br /> San Joaquin County <br /> REq(7�'11)qental Health Department SITE <br /> WW44 Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> � �1� 5�77046ll Permit Application — <br /> ENVIRpO(,NTO_ryN-R_EFUU lli PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made 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 Location Cross Street 046r l"'r'city srrrX-re r zip Y5'212 Parcel#_p,07-Oy0- 3 <br /> PROPER rxfY <br /> Owner 51,41 /YLKO A,1y'E.1'Tr6JLAddress J'f`J' <ri<n'l'KFE LN cih, .rracerc,V ZIP JSI.ZS Phone# ltP y7y<-.2POC <br /> C-57 Contractor Arm A411t ,714111`f044iSAddress 9J'8o rearm.r&P XJScityzR 10 e Zip YS65b'Lic# zr33'�L Phone#,Xce- <br /> SIZF,ren �iFd<.N? <br /> Consultant/Sub Cntr f.EEr.{°IpT, ZW Address Jc17 klt- r'e RA _City -rve:sy Lic#!3"i�'f!X phone# S/✓B6/-'PJnr <br /> GIS Coordinates:X 'y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) b DESTRUCTION (choose type below) <br /> g SOIL BORING it ROVER-BORE. DIAMETER sp ' <br /> a WELL# a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: L/Eb'' O B"e wee <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> tYMONITORING OHOLLOP/STEM DIA.OF BOREHOLE_ p MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br /> /-' e? -rYofE <br /> o EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL g PVC g OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS a HOSE <br /> U AIR SPARGEI OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: U Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING D HAND AUGER GROUT SPECIFICATIONS 1(Ed r E/7- <br /> H <br /> p OTHER: R OTHER APPROX.BORING DEPTH U BOLTED TRAFFIC BOX or U STOVE PIPE O <br /> ! CONDUCTOR CASING PROPOSED (if YES,list specifications In comment section) U <br /> COMMENTS: :TlT VN w 1-'f C-1 t-L'N/t 1 J (t <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. J <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. (L <br /> 1 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 /> SignedX/iE <-cz Title/Company <br /> Print Name—/',-. Date !-'.T <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: h I C' C' 1^TL.Jt r nl 9 <br /> WORK PLAN DATED: <br /> Application Accepted By >3 Date Issued 7i/Z 5-1 v S Area t 2-1 ri <br /> — <br /> T <br /> Grout Inspection By 1 fj" ,v...,.�_.,,� Date 3 Final Inspection By (�-,�: .-trn.� Date 3 O <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 /> 3SOZ60,00 6o`fis (,,,p i zs/�<, S R# t ( i 36G <br /> C-57_ W---WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />