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I '*01/03/2008 15:18 <br />20983565 2098350675 J6 PAGE 03 <br />San Joaquin County <br />Environmental Health Department <br />304 Last Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.co-san-joaqujr..ca.us/chd <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 9-1115.8 and the Standards of San Joaquin County Environmental Health Department. <br />3 �cs <br />I y weal. Assessors t <br />WELL Location �t,=j4W-rtM9 On treet J `'t � 51`a -Y Ci#y ��p�ip Parcel# . <br />PROPERTY J <br />owner. 3�w i4 -S- S� _ Addresss 2-0 0• f�ity,�� � Zip4 03aPhone# <br />C-57 Contractor e L.��r8"`A�dtire�ss.�, .�3'+ it �+- \ �"CtAyY ZipZlc#Phona# L3-5�i <br />Consultant / Sub Cntr-t fA& tD & , Address as �•1,�7� lyoo,Arm ACIt ' Lie# (�l _Phane# r�^7� <br />GIS Coordinates: X (d32- o.J�_ ..._, Y 1 1" .._, Township V k SJ Range �s � Section --i 7 <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOP ROBE, HYDROPUNCH, HAND -AUGER, OTHER*) n DESTRUCTION (Choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />R WELL # 0 PRESSURE GROUT <br />'*Otherr•-"-� r( r` GROUT SPECIFICATIONS <br />COMMENTS: �1 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />() MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING; 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGPRS 0 HOSE <br />Q AIR SPARGE/ OZONE 'PUSH POINT (GP or CPT)GROUT SEAL PUMPED; 0 Yes '*No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />X$011­60RING p HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: n OTHERS APPROX. BORING DEPTH 15 n BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED 9- V>- (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE- OFFSITE BORING$ 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 Ordinances, Rules and Regulations, and all applicable California State Laws. l <br />Signed x G ��^* «�4_QA�-.. _ Title/Company fi4vAct74. <br />�y q; 4Nfr 1, <br />Print Name Date_ Jl !2 .' <br />DEPARTMENT USE ONLY P'Aymis 1\;-1 <br />SITE MAP IN UNIT IV FILE, ADDRESS: ECEI` EE) <br />WORK PLAN DATED: I n KI c 1>nn0 <br />Application Accepted B " Date Issued6 t 1-6a 6k RA 66Li in k <br />Grout Inspection BFinal Inspection By ��WA Wy <br />Destruction Inspection By /ja.If�G r l,* Date ���� dJg <br />COMMENTS / CONDITIONS: /� �7Y rf'` C 4-te / ,J D f7 , - <br />ACCOUNTING ONLY; <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT I SERVICE REQUEST # <br />INVOICE <br />1 so­"oc <br />' 3 o <br />SRS <br />C-57 WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br />EFtD 29-02-001 <br />9/30/2002 v'',� <br />