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San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> iW (209)468-3449 Fax:(209)468-3433 Web:www.co.san-joaquin.ca.us/ehd UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 2 / Assessors <br /> WELL Location J`(� S{ Oti. F,r�Cross Street . Cityc 4t l p►. Zip q��z� Parcel# Wiz?QC1-O� <br /> PROPERTY <br /> Owner At,0ntJ�� �T�tnsAddressg6tf,�/�SC�fa•+ City,£ ��Zip eG52 hone#,j?Dqga$ $0,Z <br /> C-57 Contractor Address I�/nnp2 , ita City�l �Zip Lic#7r�hone# '?&" 72,79irl� <br /> Consultant/Sub Cntr/K J.x�(o4';z' w r Address PO. S7Lrl$/City,&2d ,t Lic# Phone#.9,:21,S 1? g",C <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ff DESTRUCTION (choose type below) <br /> a SOIL BORING# o OVER-BORE. DIAMETER <br /> Q WELL# ,kPRESSURE GROUT <br /> 1]`Other / GROUT SPECIFICATIONS j1a:L4<'rskcs <br /> COMMENTS: :54=c- <br /> TYPE <br /> ccTYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONlTQRING Q HOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: Z <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL )*VC a OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Il AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes [I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: a OTHER APPROX.BORING DEPTH zt O a BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: a 4 S ( A <br /> NOTE: OFFSITE BORINGS REQUIREACCESSAGREEMENT 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 Ordi a Rule and Regulations,and all applicable California State Laws. <br /> 3�1 <br /> Signed x I Title/Company /�.TCi�7f -r � o, w� t C,C�C i x 4 <br /> Print Name � Date <br /> DEPARTMENT USE ONLY ff-U �/ LQ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 6360 Cal-W F©, GI ✓—,t MAR <br /> n K 2004 <br /> WORKPLAN DATED: 3` ji 4'� <br /> Application Accepted By Date Issued z S ENVIRUNNIENT HEHI ti <br /> gr- <br /> LFX <br /> Grout Inspection ByDate 1I I S' o`A Final Inspection By I17,t�A/'Ga.. Date 4 9 G <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3<02. 60.0015 s-yy Z a as sR# -S `4,, <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/30/2002 <br />