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0 STOVE PIPE <br />• <br />San Joaquin County <br />Environmental Health Departmen <br />304 East Weber Avenue, 3rd Floor, Stockton, CA,gre02 <br />(209) 468-3449 Fax: (209) 468-3433 Web: vo,v)%ov.o/tyli <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE I <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />PROPERTY <br />OwnerSfbckibq KedeVelofMekkifYi01 Addressia. N El loittelo Fookk3r1CityNC.,k100 Zipa62ALPhone#@-07) 13q - g <br />C-57 ContractorW0alkilici Diel'U( Addres;PO 1:,tA( 33c, citXD u;sick Zip91S9-1 Lic#310031 Phone(71:03-)33-t-i — cf3o-r) <br />Consultant / Sub Cntr&ICIP.,41 EtalantlelledCress19)51 Sie.102.CityLOWiier Lic# 114'3 9" Phone(...502) 141 -31145 <br />GIS Coordinates: X , Y , Township Range Section <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environment Ith De,grtment. <br />WELL Locationg44Eter6RPA4421 We62,(64grois Street ) City Zip et 5" Lc) Parcel# <br />SITE <br />MITIGATION <br />UNIT IV <br />Well Permit ApplicatiorN94:4;/fie/kt 0106, <br />e4/ <br />ation is made in compliance with San <br />1 37 -3(9 - Os'? e • Ov\coth st. uoksii;lirn sf ) vo,,„ ureassessors <br />WORK TO BE PERFORMED: <br />NEW WELL I BORING <br />I SOIL BORING # <br />a WELL # <br />I *Other 1.14344, <br />(CPT GOPRO)5.E, HYDROPUNCH, HAND-AUGER, OTHER*) DESTRUCTION (choose type below) 2.ig Loca•thaAA DOVER-BORE. DIAMETER <br />0 PRESSURE GROUT <br />0 c 6% GROUT SPECIFICATIONS <br />COMMENTS: 13 14 c-Axlittt- 4Th so; kA3cf,n5 e.4 Acti / <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />El MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC fl OTHER: <br />fl VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS <br />O AIR SPARGE/ OZONE I PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOT : MAXIMUM FREE-FALL DEPT IS 30') <br />I SOIL BORING fl HAND AUGER GROUT SPECIFICATIONS <br />O OTHER: 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX <br />C NDUCTOR CASING PROPOSED (if Y S, list pecifications in comment section) <br />COMMENTS: -1-Ork.i CQ 4-0 L. 2x7 s <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 Or • anc s, Rul d Regulations, and all applicable California State Laws. <br />Signed x Title/Company V% u tit S t Sit'oa m tjej, A <br /> Date 7/ 30 /0 (:::p <br />DEPARTMENT USE ONLY <br />0 HOSE <br />Print Name <br />°L. <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 1/7 0 6 , <br />Application Accepted By C.-111 t C1-1 5er-1 <br />Grout Inspection By Date .3 s <br />Destruction Inspection By Date <br />Area <br />Final <br />- <br />Final Inspection By Date '5L2,7 (. P <br />Date Issued hof <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 />2 Cif) ( Ti $ ?' I 1 1 '''' -2 !ID i or, SR# Li7-It-qc, <br />C-57 <br /> <br />WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br />EHD 29-02-001 <br />6/22/04