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San Joaquin County WECE 1l PLI <br /> �. Environmental Health Department p SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 9520:AI�r 2 8 2006 MITIGATION <br /> t' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov d UNIT IV <br /> ff MNMENT HEALTH <br /> �I it Application PERMIT/SERVICE <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 tFj�Standards of San Joaquin County Environmental Health Department. <br /> 3 Z 6 Q /�J f -}� " ZZ S Assessors <br /> WELL Location ✓Z T � U' �Cross Street,v �/r����% City r"'1 Zip � Parcel# i t 160 0 Z <br /> PROPER I 11 ��S�n� �/ r ��'Z-Ph <br /> Owner L 1 y Address . y )4 Cl* Zip Phone# a <br /> C-57Tone _b- Address Qw ►�- CityC��hl��►'Zi �c# 2`{ Phone# 32-Z12R <br /> p n z <br /> Consultant/S-u\ CntrV1,�q��n,�,�:4-(�l/—Q(,:�f Address 2Z/�`re c '��� Cityl��i l Lic#_ Phone# <br /> GIS Coordinates:X �j 1 "',Y '-1 Z� 19S�t��T <br /> ownship Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING T, JD C Z� ER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# - J 'f 0 OVER-BORE. DIAMETER <br /> 0 WELL# a PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS�J TYPE OF CASING: 0 STEEL }.PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEA TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE ,PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes <br /> 0 No (NOTE: MAY,=M FREE-FALL DEPTH IS 30') <br /> SOIL BORING )fl41AND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH P 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 i ncesJRU ndReg latioonns,,Qand all applicable California State Laws.C."41'4 <br /> ;-�— <br /> Signed x �� fU Title/Company <br /> —7�c� <br /> Print Na a �%� l=r0�1 lJ Date a C? 6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: -7 1,77 © — S ��K ` 4+ <br /> WORK PLAN DATED: �_ ,L� --_0 /,' <br /> Application Accepted By_la i-a`'[�( Date Issued �� Area `"/97 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: C 4A4v& 5-� ,.e I /7n clJ S S <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> d-(701 1 C-n z �!'IL �'� SR# O BOOO <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 />