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AJAOA& <br /> to Joaquin County <br /> Environmental Health Departmen0i1 1 7 2001 SITE <br /> a < 600 East Main Street, Stockton,CA 95202ENQ Qp4j(,ifi:j j MITIGATION <br /> -1.1 <br /> • (209)468-3449 Fax: (209)468-3433 Web: wwwsjg�E �,n�ll� UNIT IV <br /> c,aotz�� Well 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 Count evelloo7 ment Title,Chapter 9-111175.3 and the Standards 1of San Joaquin CountyEnvirro�nmental Health Department. <br /> Assessors <br /> Np do- 7k N /A(JT� Cross Street ✓��G l�l buy (r O—Zip Parcel# VA S <br /> Location <br /> EF�ytxT7yy(VA21CS� e DD-e-Fa q zo9-539-9(29 <br /> PROP _Y( 9% LD611�lICS �d s 151Oo0 cyRISMArd Riiy TOZAL�4 Zip 1537("Phone# <br /> FUGF-0 COrlf'u11-- Address 13049 E�loREn AC _ GE Zip -I-'—Phone# 5 -;4 1 3•`Q7SS <br /> C-57 Contractor d Na' c4 I •!07%^7.000 <br /> (7fL57 SRP• Address <br /> 7870CAT&,0Y0A1&)Acity dF Phone# <br /> Consultant/Sub Cnlr , <br /> GIS Coordinates:X <br /> y.,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT, EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 OVER-BORE.I DIIAMETER(choose type below) <br /> B SOIL BORING# RESSURE GROUT <br /> DWELL# ROUT SPECIFICATIONS r'79%tr14Pg--rr Pte'AI's <br /> a•Other <br /> COMMENTS: CS IF Q ITAChL�D MAP AND WmIU4 PCA Al EkOERPf — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE-IL B MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> p EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS$,_TYPE OFCASING: <br /> TYPE USEEL ED PVC 0 0 GERSR �'I-IOSE <br /> p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL <br /> B AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0Yes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> B SOIL BORING a HAND AUGER GROUT SPECIFICATION t.S Fx 41-M CACP ON" '>4A "Ce"r- <br /> OTHER: f,Pf 0 OTHER APPROX.BORING DEPTH JAAEI 7©'I70 B BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CON UCTOR CASING P POSED A10 (if YES,list specifications in comment section) <br /> COMMENTS: 6x- bu <br /> NOTE OFFSITEBORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT P�RMITS. <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 i�State Laws. <br /> Q�t„ .Q Title/Company f p rE Cr IAaER /Uns a 1QQX4�an) <br /> Signed x <br /> Print Name <br /> ,P,cyaali ✓qA! Mkr Date /t>-17 07 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_efO U Rc( l A t.2 <br /> WORK PLAN DATED: W <br /> 0 b Are <br /> Application Accepted�y Date Issued Date <br /> Grout Inspedion By Data r b Final Inspection By <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> qof 85 91 , V77 /Vit j 1 " o� SR# 00 SZ 3�-Z <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit—Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />