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San Joaquin County <br /> Environmental Health Department SITE <br /> Q <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> qct FOR� <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 /> Joauin Cour1ty Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> NOT 1j' un)eve-to ) P, C'e_( 'dsg'� S. A}; Fe"+ oxy / Assessors 171 02004 <br /> oca'on 4O 352 (, (-loo-4— Cross Str et <city .JteleK1t� zip SZOro Parcel# <br /> 381- 3 <br /> 3Jr2 Zeph r aCGO� %1�— ec(VOL <br /> -ro Q�Ce4V �o <br /> PROPER 1 158ZS 91603(.,n,6Owner M�w+n OR.te9 T�U'S� Address 84(S ?-A)n� CitySA.LCitrit4N.�c�ip Phone# <br /> C-57 ContractorSQCe_'toyV,, i Address 23(,� IV�gN//l1w` JP City o��ip 952°�ic# 5i224 Phone# 2d9�465-8712- <br /> - ( ({ <br /> onsultan Sub Cntr Pa�Scst�S C'o&-o • Address 2121 K • C01'Loww Citp'a1104(�Lic� dQ Phone# �25�9�( 3�]Q� <br /> ti 16 IVA" Sol a Db <br /> GIS Coordinates:X Y Township _Range 1—= Section ?3 <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# tAW—/$ 0 PRESSURE GROUT <br /> 0*Other r GROUT SPECIFICATIONS <br /> COMMENTS: See. 1.4AL 1"A It --- <br /> u <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z'Ae4 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL )(PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ^' Sd 4-o 55 r TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:)KYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 70 tri 0 BOLTED TRAFFIC BOX or STOVE PIPE <br /> // CONDUCTOR CASING PROPOSED ►SO (if YES,list specifications in comment section) <br /> n <br /> COMMENTS: I"(At^AeA iae 4Ikt� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I Oav prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin nces u s and Regulations, and all applicable California State Laws. / 1 <br /> Title/Company S6 u�S'w- <br /> -f-& 6-e.,�D 57 9-G-36 D R sS CM j <br /> Signed x II L rf <br /> Print Name �ttGt� L e t� I h�2 e r Date 1 �� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By - Date Issued Area <br /> Grout Inspection By Date inal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: r 1 YP <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D Y DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 0 ct 1_+g� .ag� �k �y sR# 3 <br /> 2 K <br /> C-57_ WC=WAIVER_ C-57 Letter of Autho Izati t sign permit Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/30/2003 <br />