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C VIED WEtPERMIT APPLIC TION : 'SRM SITE <br /> SAN JOAQUIN COL NTY <br /> MAY 0 5 2004 ENVIRONMENTAL HEALTH DEI OARTMENT (EHD) MITIGATION <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> PERMIT/SERVICES (209) 468-344 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 Y R FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install he 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 ounty Environmental Health Department. <br /> r' _ <br /> A 1 r Assessors <br /> WELL Location L3 C��r�cr Wcc..� Cross Street i r r�� City s1bc 'L4%3^� n Zip Parcel# 0 <br /> PROPRTY ��� �/�/ggc,.Afarn.t r <br /> Owner �• A��"�� Address 21 1 ✓ [r��+. 6 1v k City pry' ipj-_52Y0 Phone#L7d4 '-193-OKI <br /> ' G . c. <br /> � p 47 <br /> C-57 Contractor>rc�.pr;l . Address L # <br /> Phone#_q -�Zoo <br /> Consultant I Sub Cntr TeeA^.la'.4_S—t Address 7o Cityf0"0 ,0- Lic# Phone# g - 433 -2-3 67 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 1]NEW WELL I BORING GEOPROBE,HYDROPUNCH,HAND-AUGER,o ER`) p DESTRUCTION (choose type bellow) <br /> SOIL BORING# 5 St3,�a 5$-� Sg-��Sg-5 a OVER-BORE. DIAMETER <br /> ,RVELL#_f-1w� 0 PRESSURE GROUT <br /> 1]*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> e <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE 8 �0 M LTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: Z <br /> —yrr cP 6a�:�5s <br /> a-EXTRACTION o AIR HAMMERIDRIVEN CASING THICKNESS- <14 Y4 TYPE OF CASING: [I STEELPVC <br /> 1]OTHER: <br /> l]VAPOR o MUD ROTARY DEPTH OF GROUT SEAL 3 TREMIE TYPE TO BE USED: JAUGERS HOSE <br /> 1]AIR SPARGE!OZONEAPUSH POINT(GPOGROUT <br /> GROUT SEAL PUMPED: XYes p No (NOTE: MAXIMUM FREEFALL DEPTH S 30') <br /> SOIL BORING [)HANDAUGER SPECIFICATIONS Po 1a.� lZZ C .•.u. <br /> a OTHER: [I OTHER APPROX.BORING DEPTH 50 AtOLTED TRAFFIC BOX or 1]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED �JO (if YES,list specifications in comment section) <br /> COMMENTS: C?t /00, <br /> NOTE: OFFSITt= 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 wok will be done in accordance with San Joaquin ] <br /> County Ordinanc I andRegulations, and all applicable California State Laws. 1 <br /> r <br /> Signed x Title/Compa y Gv� i t 1p <br /> Print NameDate S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By f� <br /> Da Issued Ar <br /> Grout <br /> Grout Inspection By Dale Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DA PERMIT/SERVICE REQUEST# INVOICE <br /> LIT <br /> P <br /> C-57 WC--WAIVER— C-57 Letter of Authorization to gn er it Encroachment c 9/30/02 <br />