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GCWOPERMIT APPLICATION F10M SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> MAY 0 6 20 4 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> PERP.91T/SERVICES <br /> ENVIRONMENT HESS i (209) 468-3449 <br /> SE <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 Co}}�}nty Environmental Health Department. <br /> �� 4Y city - Assessors Z I q f� .. <br /> WELL Locatio ��� �j�//� 1Y,O'SQ/I7/tI� /`rU'[, Cross Street /e 3S/Q- City /I'�Q/'/rLfl,L. Zip��>�7 Parcel# <br /> PROPERTY �t- N SI InS N.dcl rt LJ. Y( Mrr <br /> Owner Address y]�r Gy �ka/h/,� CitylO lj6Ce Zip 3,Ephone* <br /> COT2 C.'�^ �' <br /> C-57 Contractor �,(b QED WV Address_&]Jftt At D City �r ZipLic# AU 70Phone# 2nq <br /> SA <br /> Consultant/Sub Cntr M Address CityLid# Phone# <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> rEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type below) <br /> a SOIL BORING# S 0 OVER-BORE. DIAMETER <br /> 0 WELL# a PRESSURE GROUT <br /> U*Other GROUT SPECIFICATIONS <br /> COMMENTS: Sor'/�'¢S SAgl.'Xq <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING H HOLLOW STEM DIA.OF BOREHOLE_ D MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL R PVC U OTHER: <br /> V VAPOR a MUD ROTARY - DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS p HOSE <br /> a AIR SPARGE1 OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ;KSOIL BORING nHAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_U OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OF=SITE 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 Ord' rices, les and Regu tions, and all applicable California Stat Law;. <br /> Signed x Title/Company <br /> Print Name / /,,7&, Dale S/6/p&/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By i Date Issued 4M 1 00flf <br /> �Atr a <br /> Grout Inspection By Date Final Inspection By Date✓'. 1�---- - <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> R9 , 00 n 33 - SR# 33 5"f-,5- <br /> C-57— <br /> " -.rC-57_ WC=WAIVER_ C-57 Letter of Author at' n o sign permit_Encroachment doc 9/30/02 <br />