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" ? n San Joaquin County 1 <br /> Environmental Health Department <br /> W ;{ 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> • (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <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 /> L�, Assessors <br /> WELL Location 314 Z SOVrr r �I ��((LCross Street V VoCity QbctaN Zip igsN Parcel# 01'-07--02-11 <br /> RTY <br /> OwnnerE(.(ye Yy by`?i Address 'v oC1�l/�� O V%A b'(/�i Cit y_Se—Zip� 201Phone# (O-3470" <br /> C-57 Contractor �t I�I Address .. 32 �1 C 1p�idecity l Dar Q Zip Lic#���Phone# <br /> Consultant/Sub Cntr C/C J k'✓1 Lw; ,.i So Address City 6:a(c,KvR Lic# Phone# 714-4 3/-4IVC <br /> GIS Coordinates:X 31D i 55 3 335tY lel°16 wi'-I) 33.'jX 9,;ownship Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) OESTRUCTION choose typ below) <br /> a SOIL BORING# VER-BORE. DIAMETER 1 n <br /> a WELL# a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> ,r\ <br /> TYPE OF WELL IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE_LL a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS_S(1,140 TYPE OF CASING: U STEEL )(VC D OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS a HOSE Q\ <br /> AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') p <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or a STOVE PIPE ss <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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina s, Rules and Regulations,and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name/' --�,� ✓C�/�, � ,. "', <br /> Date G/ 2, <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By_ �>C � `� Date Issued `Area <br /> Grout Inspection By /Date Final Inspection By lrf N_'Za <br /> Destruction Inspection By P zc��.j ,[eY• DateVI �j�111 <br /> COMMENTS/CONDITIONS: �— <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ���•7 a �3Cv: W) L& SR#00gj0Y-7V <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 P <br /> 6/22/04 <br />