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mq� t� qn Joaquin County <br /> nvironmental Health Department SITE <br /> FE90f"M5ber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> .P ENVIRONMENT *AlH <br /> PERP�IIT/SERVI I Permit Application <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 /> WELL Location 6/OD,yiRfy N/-11141-4,'17 Cross Street //A.N-4'Ae/*'eci Jrietso f/ry Zip 952/2 Assessors <br /> Parcel# DPJ— OyfJ-�`� <br /> PROPERTr <br /> OwnerJr CGNNOt VIKD�T1�fOAddress t/( (il r^t+(u.c C,cn City$ bszIPY5�I> Phone#yy. <br /> Co /77d9 `1 T'`l-Z�s� <br /> C-57 ntractor A'G< Ex dtle�•AutJ y Address 9.380 COMA7y PAR f?J City TiOALAfV to ZIp off fr LIo ZyAp`hone# <br /> Consultant I Sub Cntr J&�VA' Address 2017 ,ryrse4°E,t•Afre/0�ry ' vt 11104 Llc#6r�`i'Yr Phone# �/s�!/•®vex-zry <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) kDESTRUCTION (choose type below) jr kiorz4f <br /> 0 SOIL BORING# ROVER-BORE. DIAMETER AJ " fir A#-,?,,LLk'3AW-Y <br /> WELL# O PRESSURE GROUT _ <br /> 1]*Other GROUT SPECIFICATIONS <br /> COMMENTS: fWLl�S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )(MONITORING )(HO�LL� �VS�;yE DIA.OF BOREHOLE_ 0 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 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 D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 'il �`1rfL T <br /> 0 OTHER: D OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �1— / CONDUCTOR CASING PROPOSED (If YES,list specifications in comment section) <br /> COMMENTS: 1 Yt M 1M%.:,e [�r('H <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 Std;e Laws \ <br /> isefiJ <br /> Signed x�. .. Title/Company.. <br /> Print Nameo-'loe/f/:.r Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 01 <br /> WORK PLAN DATED: -�-x fE i L�2vp 5 <br /> Application Accepted By (i1� Date Issued �QS Area h 7.i 9 <br /> i --� <br /> Grout Inspection By l.��'IMnPw� Date Z Z$ O Final Inspection By �S OF Date <br /> Destruction Inspection By Date - <br /> COMMENTS/CONDITIONS: -zi Lo -3 G , � <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3502 40,00 6n`5�s tj SR# '�5 <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 />