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05/18/2004 14: 12 2094683433 FIFTH FLOOR PAGE 02 <br /> �i -W <br /> *FO <br /> San Joaquin Counteru u���� V P�EEnvironmental Health Department I� )304 East Weber Avenue, 3rd'Floor,Stockton,CA 95202 MITTGATION <br /> (209)468-3449 Fax: (7,09)465-3433 Web:www.co.sanjoaquin.ca.us/eY 1 7 200dNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br /> PERMIT/SERVWF <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application Is me mpliith San <br /> ance w <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> _ 'j[']x ,�. Assessors <br /> WELL Locatlon;23 T/ [ Cross Shead —�cit ZIP � Parcelft <br /> PROPERTY L( <br /> Ovmar G Address l 5, M� Ity� •�Z'P�q �� Phone7Fg !y <br /> C57 Contrector ft0fn _ Address •0. clry IJ- Zip/7 ftlC,I,Lirc# 760hvne# qJ�r' 7 <br /> Consultant!Sl �l i7itO [r( �L, Addre,-;792 KT a Clty-s-1 l- —Lie# r V� Phonon 26� [ %D-13Y6 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORIN (C ,GEOPROB ROPU AND-AUGER,OTHER`) Q DESTRUCTION (moose type below) <br /> 0 SOIL BORING 0 a OVER-BORE. DIAMETEF� <br /> 0 WELL I]PRESSURE GROUT : <br /> Ora 1 ,I GROUT SPECIFICATIONS�. L-11_C£ ,..11 CL■+U <br /> COMMENTS: SGS IJcf aA. CA. �W 1]D/iAr-1 �.6�G.tTuAp <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATI NS <br /> _ 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS 13 MULTI-LEVEL WELL CASING DIA: <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ()STEEL PVC 0 OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED' D AUGERS 0 HOSE <br /> AIR SPARGE!OZONEPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 13 Yea 0 No (NOTE' MAXIMUM FREE-FALL DEPTH IS 301) <br /> p SOIL BORING 11CC❑❑��HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER'_ 0 OTHER APPROX.BORING DEPTH 1 0 1 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 certify t at I havLppared this application and that the work will be done in accordance with San Joaquin <br /> County Ord'f�a ccs alulations, and all applicable Californ 7luyn/q�tate Laws. )� <br /> — <br /> Signed x <br /> Title/Company r L-� 1 <br /> Dale <br /> L. <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: -75 { <br /> „-(,Q Date Issued �d �0 Area;c5'!� 9� <br /> Application Accepted Byj ti <br /> Grout Inspection By Oale Final inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> mv"T615- <br /> AIO# FAC* <br /> AMOUNT REMITTED CHECK# REC•D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> g9 IZI Z� / / sit#Gtz73$aG7 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> E140 29.02-Do I <br /> 9/30/2002 <br /> 05/18/2004 TUE 15:07 [TX/RX NO 54071 Z002 <br />