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_ FILE <br />COI <br />r. rs }f 'P <br />. "�.. _ �.ru�':•'3:. <br />Qan Joaqujfi County o <br />Environmental Health Department ED <br />m5 m 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202. MITnIG�ATION p� <br />r`P < (209) 468-3449 Fax: (209) 468-3433 Web: www.co.san-joaquin.ca.us/ehd 1 N*M U <br />4.,,6 -0 EN <br />VIPAPIAI <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES - <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 9.11 15.3 and the Standards of San Joaquin County Environmental Health Department. , <br />�� �l2 m� T Assessors <br />WELL Location Cross Street Cily 1 r� Zip Parcel# ! !� <br />a3 <br />C-57 <br />Consultant / Sub CntrTI (� ,n mak—_ \� naaress � � i �w �Knx o wr • - - -- —r -�—�-- <br />GIS Coordinates: X , Y - , Township Range Section <br />s <br />ORK TO BE PERFORMED: - - <br />EW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) a DESTRUCTION .(choose type below) <br />aSOIL BORING# !i DOVER -BORE. DIAMETER ; <br />-)@VJELL# M l.J7 - a PRESSURE GROUT - <br />O'Other �+ GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE - CONSTRUCTION SPECIFICATIONS <br />`MONITORING y HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br />p EXTRACTION ,0 `AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL.;, VC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:IGERS O HOSE <br />p AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes No NOT :MAXIMUM FREE -FALL DEPTH IS 30') <br />p SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />Tfir- <br />0 OTHER: 0 OTHER APPROX.—U. DEPTH I / a BOLT D TRAF C BOX or p 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 that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County O"ances, Rules andd�ggulat�ions, and all applicable California Styte L� ! ! � <br />SITE MAP IN UNIT IV FILE, ADDRESS <br />WORK PLAN DATED: f= <br />Application Accepted <br />Grout Inspection By_ <br />1n..cuTC r rnummnus- <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />RECD BY <br />DATE PERMIT/ SERVICE REQUEST # <br />INVOICE - <br />350 <br />� <br />3059 <br />C, <br />7- I sR# p3g <br />C-57� WC J -WAIVER_ C-57 Letter of Authorization To sign permlrvt cncroaonmrn, <br />EHD 29-02-001 <br />9/30/2002 <br />