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San JoaquikCeunty <br /> Environmental Health Department MAY 12 2004 SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95MIRONMENT I&RATIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.co.sanjoaquinPFRW#8ERVIEES UNIT IV <br /> ` NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> —-._—APNeaSenIs hereby made to San Joaquin Counlyfor a permit to eonstnict and/or Install the work described.-This application Is made in compliance with San. __-._ <br /> Joaquin County DevelloogQnent We,Chapter 9-11/115.3 and the Standards of San Joaquin County <br /> �EmAnronnmental Health Department. <br /> WELL Location /�L l I ✓!. Crosti Street JTI7r1 ilr Cit9'���g L •03 <br /> neM�r ,n/ are a /593 ��.�a tri rl�l�'ciy� zip ^°nom 39 <br /> C-P Contractor r 1 Addre"a&1f�" C�e�) zjp—gg &&221/Phora3i9��y j <br /> Cons ifte t/S ib C ti AddressZ7,k—//�t•#k?/) ChyAW_Lk�/,5/5C /Pnone�-/17_S.Q' <br /> GO Coordinates:X ,Y Township Ranee -Section - <br /> TO E PERFORMED: <br /> EW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND,AUGER,OTHER•) 0 DESTRUCTION (choose type bebw) <br /> a SOIL SORING S - a OVER-BORE. DIAMETER - <br /> LL# 0 PRESSURE GROUT <br /> 0.Otlur GROUT SPECIFICATIONS <br /> COMMENTS: i <br /> STR <br /> JIMAICKS <br /> rg'E•ONITORING LOW STEM DIA OF BOREHO a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: __ <br /> ON MERIDRIVEN CASING THICKNESS TYPE OF BASING: 8 STEEL�/C 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TWE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:XVes 8 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS I44jdnh><' <br /> 0 OTHER: R OTHER APPROX.BORING DEPTH /S 2Q In*LTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ti() (If YES,eat sped5allons In continent 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 Ordinang2jKules and Regulations,and all applicable California Stats Laws. / <br /> Swredx Y G TWe/Company fRa�eT K*A+A6EX AgypxoAwO r-fL- <br /> PrIMName - . r iGr BL(/NS Data ✓r V/G ,�iVL' . <br /> DEPARTMENT USE ONLY <br /> / <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ' rs <br /> WORK PLAN DATED: <br /> Appialim Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection ate <br /> Destruction Inspection By D <br /> COMM MICONDMONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK if RECD BY DATE PERMIT/SERVICE RECUEST# MVOICE <br /> VITO 3 s S0039017 <br /> wag <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign pemitJL Encroachment doe_ <br /> EHD 29-"l <br /> 9130/2002 . <br />