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=caygD <br /> San Joaquin County <br /> Environmental Health Department MAR 12 2004 SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 9526NVIRONMENT HE,��NITIGATION <br /> �' It�SERVICES(209)468-3449 Fax: (209)468-3433 Web: www.co.san Joaquin. a. IV <br /> �ts0R� <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 /> yo y 1' i 1 4i',' <br /> r y� �i '1 p Assessors S` Cp <br /> WELL Location W C c.' JZCross Street Cit 7CC/L Zi Parcel# /y � 7��& <br /> PROPERTY / n <br /> Owner 1W�Qr- Voa.'LC S Address 2�-tt 2- NrCIAIS K�� City ti Zip� 3Z Phone# <br /> C-57 Contractor\!'IAW � ' )lo r&Addressiu li&k wL ' City'S`�tL�1l Zipt I Lic#�'�,cM Phone# 11L---M-t419) <br /> Consultant/Sub Cntr Afte-/ 16'`N L I Address l Y f Y 7 Wlt y City_SLic# Phone# 53,?- ��Z <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> gNEW WELL/BORING (CPT,GEO ROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> `SOIL BORING# C?to PE �i_ 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other 1 GROUT SPECIFICATIONS <br /> COMMENTS: Ur /o b-o f itiS n Tll6 MSX I de�f� �� /� Cr.�C'h W0 w—niel— <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE I•S� 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 /o, TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE .PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: IV�/AIXI/M/ UM FREE-FALL DEPTH IS 30') <br /> *SOIL BORING O HAND AUGER GROUT SPECIFICATIONS Nt 44 C Q rwtn >L brn7t,�r 1, w Su:r{u C L <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH /C' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED No (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 Ordinances, Rules and eg lations, and all applicable California State Laws. <br /> Signed x '�` 'w // Title!Company peg ua u n u F�• /�/'t`'✓/�4 i CTeu <br /> Print Name Ci It,\ L,v Date 9 C y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By �� <br /> a l\ to Issued /' 1 I r I� Area <br /> Grout Inspection By 1.11,jmziate nal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITI NS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> (4 ( SR# — <br /> C-57_ WC -WAIVER_ C-57 Letter of AuthQ�lzo'tion'4 o sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/30/2002 <br />