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San Joaquin County <br /> � nvironental Health Department <br /> ' 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 <br /> 20%4d-3449 Fax: 209 468-3433 Web: www.sjgov.org/ehd <br /> �} Q 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 /> -5 �z �� L 1 ] `� S�Z�� "12.x/_ Assessors � <br /> WELL Location Li 2- 6 Cross Street �V City i\ Zip JUtt' Parcel# H4_02_61? <br /> I <br /> PROPERTY�y��t�� / f / i' r(� <br /> Owner CWl'f/�1Vv"� Address I��yy ll� City .�'i,rV�e-l'"WI Zip�t`C�� Phone# �l�iJ'" <br /> C-57 Contractor (�l`x;"'`� �� I Address,��� �� �,1' 'City C& a AZip qVW Lic# I`�Phone#-��' f� 'lU.� �I�l6 <br /> Consultant/Sub Cntr lW1�1�],[_ r �S641iess AS2_1 Mai. FIS} �'i ity r` �Lic# Phone# t(`i��1I-�[W <br /> GIS Coordinates:Xaa D ar i�l 3 "!>TCY (_a.l0 i�M',1.�-q�ownship I,V Range �n 7 Section <br /> WORK TO BE PERFORMED: <br /> D NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose type belo�!) <br /> SOIL BORING# VER-BORE. DIAMETER_ V1Gy� <br /> D WELL# D PRESSURE GROUT <br /> D*Other ROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING AOLLOW STEM DIA.OF BOREHOLELL D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS �-tq 91) TYPE OF CASING: D STEEL �VVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: D OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or D 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 Joa in <br /> County Ordinancldss�Rues and Regulations,and all applicable California State Laws �� �L(t��44 <br /> Signed x F' �L� Title/Company V V \ ln�i� TiV t� (0 P-, �P Id�D I �i v7n <br /> Print Name�., F y'E V �( Date r V <br /> DEPARTMENT USE ONLY <br /> PAYMENT <br /> SITE MAP IN UNIT IV FILE,ADDRESS: BEHO LVED <br /> WORK PLAN DATED: <br /> /e 2006 <br /> Application Accepted By *-�/Y 76ig-0 Date Issued 6� ®�� Area <br /> Grout Inspection By Date Final Inspection By dIN COUNTY <br /> Destruction Inspection By -ir Date �5 /C Z Od ENVIRONMENTAL <br /> COMMENTS/CONDITIONS: L'an!2"ew ��:�t►�l 'f' /�Z "jam /��� % <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> tf:-? � a23fo K& p SR#pp IFY <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 />