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�c�u,n;• Sall Joaquin [runty <br /> EnV �-€�nmental Health Depal-tsnent , :_ <br /> }' � 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 �i��` > ,���� l_TE <br /> 4b TION <br /> 5' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT V <br /> 2D0 _ <br /> ell Permit Application ' _. <br /> NON-REFUNDABLE PERMIT EXPIRES 4 YEAR FROM ]ATE ISSUED Ef all �3;'aI'! W <br /> rF, /��r� <br /> ApplicationIs hereby r tatle to Sacs Joaquin County for a permit to construct andlor install the work described. ThisFa� <br /> andards of an Joa ��I 1 4�#i'LW[Ei�mpllance with San <br /> Joaquin County C�e��i� ^� Title,Chapter 9-1 t 15,3 and the St County Environmental Healthy(Department. <br /> Assessors <br /> WRl L Location_ lJ Cross Slreet_.L�l [GGL,GQ City �1 Zlp k5� c7 Parcel## 2t 3" t«- 0 3 <br /> PROPE TY <br /> Owner �i ��, 5(r .<� Address 3 trt7. _U,i� Cityls`�l 53 Phone# <br /> C-57Gontractory`v�lrv' 1r Address L ! T�(r. —Gity L�� e�o� Zip <br /> Consultant JSubCnt€ juge�, Inc Address '2'C� ]_ dr y---City fir„ Lic# Phone# f>`{ tC <br /> GIS Coordinates:K _„ ] _., ,Y Township Range Section <br /> WORK TO RE PERT ORMED; <br /> U NEW WELL/BORIPNG (CPT,GLUPRORE, HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION (choose,type below) <br /> 0 OiL BORING# 0 OVER-BORE, DIAMETER <br /> '0the€ELL# p,. � 0 PRESSURE GROUT —� — <br /> 01 _-- -- GROUT SPECIFICATIONS _ <br /> COMMENTS: _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r a� <br /> R MONITORING flLLOW STEM DIA. OF BOREHOLENALt <br /> MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Lf] EXTRACTION B AIR HAN'MEWDRIVEN CASING THICKNESTYPE OF GASiNG: Q STEEL pVC OTHER;0 VAPOR 0MUDROTARY DEPTH OF GROUT _ TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> Q AIR SPARGEI OZONE lJ PUSH POINT(GP of CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MA CIMUM FREE-FALL DEPTH lS 30`) <br /> [l SOIL BORING U HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:__ ij OTHER_—_ APPROX,BORING DEPTH, - 0 BOLTED TRAFFIC BOX or TOVE PIPE <br /> CONDUCTOR CASING PROPOSED {if YES,list specifications m comment section) <br /> coMM>=Nrs: <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 antes, Rule and ReIgulations, and all applicable California State Laws. <br /> Signed x - TitlelCompany �O <br /> Prfnt mC Date_ / k <br /> DEPARTMENT LIS ONLY .�,—�� �� <br /> SITE MAP IN UNIT IV FILE, ADDR <br /> WORK PLAN DATED: ~e <br /> Application Accepted E3y_. _ —W _ —Date issued r _�-_..__Area <br /> Growl Inspection By___::! _ Date Final Inspection By _ Cate_ <br /> [destruction Inspection By Date <br /> COMMENTS f CONDITIONS: <br /> � ACCQUNTfNG ONLY: Fli6# _ FAO# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> - �R# �6 <br /> C-57 WC WAIVER— C-57 Letter of Authorization to sign permit Encroachment dot <br /> LAID 29-02-001 <br /> 6/22/04 <br />