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E DD <br /> paU... San Joaquin County <br /> Environmental Health DepartmerWR 2. 0 2004 SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> ' (209)468-3449 Fax: (209)468-3433 Web: www.co.san-j4AfJN ,,HEALTH UNIT IV <br /> ERIVIIT/SERVICES <br /> �rFQ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> lic io s h r b adeyoaquin County for a permit to construct and/or install the work described. This apptication is made in compliance with San <br /> Jo Co a opmeChapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 73z)(.7 C ha ane S/'- _Cross Street IV. 6--7 ' f'r- City Sra<-V t-7 Zip fr'2o 4 Parcel# <br /> PROPERTY <br /> OwnerRa .�r..r� 1 nv�r�,c'r Address �*7 S. Ccetrer- Sr`, City Sri Pc Zip rrZ�L Phone#«�) rL4 "�GaY <br /> C-57 Contractorr_S--7;c- Addressa-7P N, tui r sr. City�I­ALu.rd_Zipjr77(� Lid* Phone#(f f3 )?;Cz�vzy <br /> Consultant 1 Sub Cntr r!�'-74r Address SK: -r Lic# Phone# <br /> GIS Coordinates:X Y Township- _Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (C T,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> ,WSOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# R PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS:C?j'--,.r" Z ���. J c,lie t_t- f;i' a--I,l ni, il�w�r Ter irr 1c <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 'f 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N4 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER; <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Y tTREMIE TYPE TO BE USED: 0 AUGERS •'0 HOSE <br /> 0 AIR SPARGE!OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: p'Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS e,,_t cerrrn�r <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH Y f 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> n CONDUCTOR CASING PROPOSED M,0 (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. r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin" <br /> Coun dinan/c�es,f � ,A Rules a�lnd Regulations, and all applicable California1 ,Sta`teeLLaws. <br /> Signed x ` l.� '4 1 Title/Company V ' <br /> Print Name� �l�� �1I�J LE Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: E f C ha Yin al S <br /> WORK PLAN DATED: qq __ O <br /> Application Accepted Bfy u ii r'+,S i 6- L IVIL� C Lt r�ll t Date Issued r- zo 2,U o A' Area 14:5q <br /> Grout Inspection By Y uef err a~ �.. m��h�/ffi,Date z Final Inspection By ate li <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: S S <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 35x1 9q. ad 8 , Oo O� l87G SR# 60.3 '7493 <br /> C-57_ WC--WAIVER— C-57 Letter of Authori2ation to sign permit Encroachment dock <br /> EHD 29-02-001 <br /> 9/30/2002 <br /> j <br />