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Ec�u;� '� San Joaquin County <br /> Environmental Health Department SITE <br /> FLS 1 g;OI t Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)46 �i <br /> - Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> • c,Fo N P ENViRONM`�NT C�Vell Permit Application <br /> PERMI�ISER <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 /> Assesso <br /> +til P e'414 City'4reee�.f Zip 9.sz/,� Parce#r�/6HT-cF- tcAY <br /> WELL Location�h'>'99/R.0���0 - �EL'��N�7e�Cross Street H�frL/E, <br /> PROPERTY <br /> Owner !/GL 'Ti°,F,fS Address /,Y%T"a 1°Ff' City Zip fSzc/ Phone# ('�Zrf <br /> C-57 Contractor '+J/'!llSAddress ln <•'+•%+':ii13'.iy 91d city' .Wt ! Zip9s6%$Lic#1d 73IC Phone# c°OC d>j-3G73 <br /> Consultant/Sub Cntr f6<114' -iW7 ZWe; Address JceZ hlECff.POS Clry Lo+lnPA Lic#/f 5'0 Phone#/ P//OYOo «Y`J <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) %DESTRUCTION (choose type <br /> 0 SOIL BORING# below) <br /> OVER-BORE. DIAMETER Ab <br /> H WELL# 0 PRESSURE GROUT <br /> p*Other GROUT SPECIFICATIONS <br /> COMMENTS: /oV4 ele ell --- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> (MONITORING XH�y�O�WySTEM_ DIA.OF BOREHOLE_ n MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA:------ <br /> a EXTRACTION []AIR HAIi NDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC E 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 H No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 42� -W7 lFi�lEiYT <br /> 0 OTHER: H OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> COMMENTS: 1 <br /> ONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) C <br /> i/�O VN VL�.I,'1,�17 0 <br /> U <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. J <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin LL <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signedx 1495��,�- Title/Company ii<ff!!06/S�SF/CO.�Imo;.rq�:sT1D.YAL Il� <br /> Print Name ��/ r Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 15(h C NZ c3 <br /> WORK PLAN DATED: (( �7--C>OS T <br /> Application Accepted By Date Issued L S` Area 4Z 09 <br /> — <br /> i <br /> Grout Inspection By ,h,.,,.,,moo. <br /> I — Date 3 ® Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES <br /> FEEINFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> 35-0Z �orcc> 6C�Yg z zs'(c/s' SR# r� (350 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />