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A <br /> WELRMIT APFLICATION FCOM <br /> -- SITE <br /> MITIGATION <br /> SAN JOAQUIN,COUNTY vlROfdMEN(Ai. WEALIN UNIT 1V <br /> r"DIL-1 T SERVICE ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> 3 DEC <br /> r 38 PM 3: 48 (209) 468-3449 <br /> CSV Tf 09 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ppliration is hereby made to San Joaquin County for a permit to construct and/or install the work descnbed. This application is made in compliance with San <br /> caquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> /1 /n� � s c-04oL .4vZ ff Assessor's <br /> TELL Location (2921 C1)Yl4'L !'/VE • Cross/Street T+NoANrnn RDCity Fo0f Zip 9� Parcel# o$5-3Zo ' Z4 <br /> 'ROPERTY Owner /ilCf�HR� BoK QE) Address Y O BoX ly/� City lhl o,_j&i jV Zipa5i Phone#zorl -36� 9330 <br /> -57 Contractor C, F, Address S 3 7 SN,4�✓ A 0 City .S TSXY, zp 95Z6r Lic# .Z Z 7Phon Z 19 i Z a <br /> :onsultant/Sub Cntrl! G' � Address?> �'1-)/}w kD City STcC IfT9.'V-ic# Phone# ZnY 1/ 7-!pn b <br /> —C-5 ZZ� <br /> 11S Coordinates:X ,y.Township - Range Seciicn <br /> rORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> NEW WELL/BORING( , GEOPROSE,HY ROPUNCH,HAND-AU -R OTHER-) 0 OVER-BORE <br /> (chops type <br /> OIL BORING# 3 rq -4yy yl RESSURE GROUT <br /> 0!. W ELL# <br /> ?the <br /> Grout Specifications: OfT/A+vO 0� <br /> :OMMENTS <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z`r MULTIPLE CASINGS?1]MULTI-LEVEL?o WELL CASING DIA.' <br /> EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS NIT TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: /116 <br /> VAPOR `]MUD ROTARY DEPTH OF GROUT SEAL S9 TREMIE TYPE TO BE USED: 0 AUGERS OSE <br /> AIR SPARGE/ozone gPUSH POINT GROUT SEAL PUMPED: 0 Y s �No (NOTE: MAXIMUM FREE-FALL DEPTH 1 30') <br /> SOIL BORING O HAND AUGER GROUT SPECIFICATIONS: Of I MNO Z. oc- <br /> OTHER: p OTHER APPROX.BORING DEPTH 50' D BOLTED TRAFFIC BOX or (]STOVE PIPE <br /> C'cc (A1 ✓ n <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: /GS- OQh PlAr\2 M cider Alin I '7 Zoo_) _ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> :ounty Ordi"nces, Rules and Re ulationsI and all applicable Californiafg/state Laws. �5q <br /> Signed x TiHe/Company /,r�.O�Fr .6 <br /> 'riot Name u I Date L� <br /> UtzVARTMEN I USE ONLY w <br /> 31TE MAP IN UNIT IV FILE, ADDRESS: <br /> NORK PLAN DATED: h 0 i1 fly Area U <br /> >pplicetion Accepted By Date Issued - <br /> Grout lnspectlon By <br /> DateFinal Inspection By l,:,a . 11 ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDMONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> o -71 <br /> 9 /- 7 5W--&V)/ :77 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permi Encroachment doc A8/29/02 <br />