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10/26/2004 09 50 2094683433 FIFTH FLOOR PAGE 02 <br /> �F-. v J (0) 1 rg <br /> OCT 2 5 2004 1 �RM <br /> ��1VFLhL PERMIT Q L SITE <br /> MITIGATION <br /> Qu t .el fo E �,, E ,VIt E, SAN JOAQUIN COUNTY UN IT IV <br /> Si ,J� M Uj ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 7.285 b•Fv�wSfi`• 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> ND-REFUNIIABLE ERMIT E FIRES t YEAR FROM DATE iSSUEb <br /> A 50m= n rs hereby trade to San Joaquin County for a pennd to canatruct andlor install the work de; nbed This application is made in compliance with San <br /> ,lo3ge,10 County Development Tille,Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department Assessors <br /> WELL Location Z Cross Street City zap Parcel#AL�7�? <br /> PROPERTY Owner v1_ ` i ddress��5 •• Cif7rJ��rp Phon87F 61 fl <br /> Phone# <br /> C-57 Contractor d D. Adddre/ss Q1 a <br /> • (aKlt[+�J1it�[ ddress vFtv 114 <br /> rtyUbLicit. one# <br /> Consu Ito nt/Stab Cntr f <br /> GIS Coordinates �,-_ _ <br /> •Y i ownship Range Section <br /> WORK TO Bt PERFO MED p DESTRUCTION (choose type below <br /> (VIEW WELL1 BORING(CPT,GEOPROBE,HYDROPUNCH,LAND AUGER,OTHER'} p OVER-BORE <br /> p SOIL BORING ty 0 PRESSURE GROUT <br /> i+VELt# t Grout Specifications <br /> •Otfier <br /> COMMENTS <br /> TYPE OF WELL _INEIALLATIQN TYPE CON IUCT N SPE IFICA <br /> re <br /> �AONITORING �IOLLOW STEM DIA OF BOREHOLE MULTIPLE CASfNG$?QMULTI-LEVEL?Q WELL CASING DIA <br /> TYPE OF CASING (}STEEL )KPVC 0 OTHER <br /> 0 p{'TRACTION Q AIR HAMMER1DRIVEN CASING THICl4NE5S�, L�` �EMIE,I,YPE TO 8>:USED t1GERS Q HOSF <br /> t• �VAPOR Q MUD ROTARY DEPTH OF GROUT 5EA.,...�s <br /> 0GROUT SEAL PUMPED QE-Yes ?"o (NOTE' JAAXIMUM FREALL. DEPTH IS 30 <br /> AIR SPARGE!OZOl1e Q PUSH POINT <br /> SPECIFICATIONS <br /> 0 SOIL BORING 0 HAND AUGER GROUT <br /> BORING DEPTH �$OLTED TRAFFIC 80X or 0 STOVE PIPE <br /> Q OTHER—0 aTHEFt_,_._� <br /> CONDUCTOR CASING PROPOSED? .(tf YES,IEst specifications here},_ <br /> •COMMEF 75 <br /> CHMENT <br /> NOTE: OFFSITE BORINGS REQUIRE LJA HOURSESS INAlaVOAN I� FOR ALL REQUIRED iN PMC SONS <br /> CALL.THE UNIT IV INSPECTOR 48 W <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> Cai•tty Drdinan les and Regulations and all applicable Caltforni State L w _ <br /> Sgaed x <br /> ,{y Title/Company <br /> •G. 53rd- Rate <br /> prr` N DEPARTMENT USS ONLY <br /> LDP <br /> SI'T'E MAP IN UNIT IV FILE, ADDRESS; <br /> WORK PLAN DATED' <br /> Date Issued fry Amo <br /> Appbcabon Accepted By Flnat Inspection 13y pate,.._ <br /> Growl Inspection By Date <br /> Desfrucbon InspeCborl BY Date <br /> COMMENTS CONDMON5 <br /> • ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK 0 REG'D BY DATE PERMIT!SERVICE R>=QUEST t{ INVOICE <br /> r <br /> 11 of o r4-Z-s' QD 0l0-3 <br /> C-557 INC -WAIVER -57 Letter of Authorization to sign permit! Encryet d O <br /> �� <br />