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San Joaquin County <br /> 2{ Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> 1% (209)468-3449 Fax: (209)468-3433 Web: www.co.san-joaquin.ca.us/ehd UNIT IV <br /> q<<fioRN <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 /> � n�� 1 / `Assessors <br /> Locatio GAdL hhh 4 t�a/�1f�'ross Street City> � L Zip 7�t7 Parcel# <br /> PROPERTY^ DO(— 7 v 0 <br /> Owneru Ic6.174A• Address 15334 L,4 SA City.% CI AI Zip�� q 2 Phone# (,7—03�671 104 <br /> C-57 Contractor Zu 1 �G Address 'b p�C �j _City ( t `t Zip�_Lic�I��Phone#( oO—A(' <br /> Consultant/Sub Cntr K LOj AFr-1C Q] Address Z P City Lic# Phone# /W171 3 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PE <br /> p NEW / ORIN (CP , EOP E, DROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type below) <br /> SOIL G# p OVER-BORE. DIAMETER <br /> a WELL# &PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS_L IOU UUe— <br /> COMMENTS: IN �� — lu (jA's GUI '5441 S�W*,, l F L p r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SP FICATIONS <br /> a MONITORING a HOLLOW STEM DIA,OF BOREHOLEAt MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:------ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> a AIR SPARGE/OZONEI*I-ISH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes p No (NOTE: MAXIMUM FRE ALL DEPTH IS 30') <br /> a SOIL BORING V0 HAND AUGER GROUT SPECIFICATIONS 4-- CfOVAJ I <br /> 0 OTHER: a OTHER APPROX.BORING DEPTH 31-)t BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 certifytQ I haveprepaAd this application and that the work will be done in accordance with San Joaquin <br /> County Ordi n , an egulations, and all applicable Californiaate�1 Laws" <br /> Signed �Z <br /> Signed x Title/Company r/r I Cv� nn <br /> Print Name G / �� <br /> Date � Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 5-- l6 0> <br /> Application Accepted By Date Issued Are <br /> Grout Inspection By Date Z.SS O`S Final Inspection By Date <br /> Destruction Inspection By Date <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 /> 01`101 8`�. � zF,33 SR# Zy O <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/30/2002 <br />