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FILE COPY <br /> San Joaquin County <br /> Environmental Health Departm,�'Ww wAt- FiEA a'-I SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 9520TIDMJT �rq,/lCF MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgovv..org ehd 2 AM UNIT IV <br /> /FOR`'v NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS ED rL <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 /> T� /��/',�vD zip �,�b Pasrcea# /96-y74'Z/ <br /> rs <br /> WELL Location /denn/_.n..RififiLG /.ZG cross street /7'ui Li/jty�ciry-��=T <br /> PROPERTY �, G�/,s�f� �..w 9 �+aXJ Phone# <br /> Ownercl* JrAddress /1wr/ C�nndrt�Dl�. City IN22������Z�P /���� <br /> �r✓dt •QD City'��v .L12-Zip_LLic# /OG7 Phone# 707-37%—f/ o <br /> C-57 Contractor��� 12 A/f A/AYfddress �� <br /> Consultant/Sub Cntr -5cWl� Address��/�f�T� C�h1 ✓ ic# Phone# <br /> GIS Coordinates:X <br /> Y ,Township Range Section <br /> WORK TO BE PERFO <br /> {NEW WELL/ NG (CPT,G PROBE,HYDLPUNCH//HAND-AUGER,OTHER') <br /> [ DESTRUCTION (choose type below) <br /> 0 SOIL BOR -/Z. Gf"37�-/�� 0 OVER-BORE. DIAMETER <br /> 0 WELL# a PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> o*Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING O HOLLOW STEM DIA.OF BOREHOLE/U MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA:— <br /> U EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:. O STEEL D PVC Il OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL /SL TREMIE TYPE TO BE USED: U AUGERS D HOSE <br /> U AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: *Yes Yes Iaa No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> aOIL BORING U HAND AUGER GROUT SPECIFICATIONS <br /> ORING DEPTHS <br /> O BOLTED TRAFFIC BOX or SxTOVE PIPE <br /> a OTHER: []OTHER_ APPROX.B <br /> CONDUCTOR CASING PROPOSED O (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 Ordinance,9 Ruu! s/and Regulations,and all applicable California State Laws. /� <br /> Signed x�� �f' Title/Company / ��L✓ <br /> Print Name <br /> DEPARTMENT USE ONLY Date <br /> le �� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Zfb3 <br /> WORK PLAN DATED: Q <br /> Application Accepted By Dale Issued r v <br /> Area� <br /> Da <br /> Grout Inspection By te Final Inspection By e <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODESFEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 5d1 SFS S`j---- 'V'] 3Y �'7� sR# 0 3� 7zi <br /> C-57_ WC_I[-WAIVER_ C-57 Letter of Authorization to sign permit_ Encrment doc_ <br /> EHD 29-02-001 <br /> 9/30/2003 <br />