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EnvWnmental Health Departmek-`00 �L) SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95q ' MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.: v.org ed f �0OS UNIT IV MU <br /> °NpVri�N,ONM.ENT HEALT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE'tsst.�++T�SE�t✓10E H <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 /> WELL Locatlon_Zyq 1 F,x_Si- Fh1"Aoy�k 9- Cross Street)J, I6cr+ St Ci c Assessors <br /> F' h �_LL! 1 _Zip S Parcel# I-2 L{-Z. <br /> PROPERTY Di55k-L,-A W�d,LLC- <br /> Owner <br /> LC. $k��e.l y <br /> Owner�$Cc}} S. f7amcu.N\ Address 7i�oU�"�L�i"Cwa�eF Snt e1 City $')-oc.k+U" Zipg5)i`j Phone# (ZACj) LL(p� 6$ <br /> C-57 Contractor(7rPAG 7ri11;ka }y f I ddress I fTlJ�7�. 1 c Ci <br /> //�� 1 7 ty�e-ZiP y b5-3 Lic#Hu S 16 Phone#_2l 2- 313-$�XD <br /> Consultant/Sub Cntr_IAW�J/1a uVlrgtwtCN-4a�dress_Z J Pey VitACS 5' CityJwta Lic#/_ Phone# <br /> GIS Coordinates:X ,Y ,Township_ I N Range l0 ' <br /> Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING (CPT,GEOPRO$E,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# 5_}� S- <br /> 0.Other PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS_ /'\A.W W Z��S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING '-w"IOLLOW STEM DIA.OF BOREHOLES MULTIPLE CASINGS <br /> XB MULTI-LEVEL WELL CASING DIA: 2-/r <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS,5C 1. 4 d TYPE OF CASING: 0 STEEL )KPVC BOTHER: <br /> 11 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS LiOSE <br /> 0 AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ' Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Cel- <br /> 0 OTHER: Il OTHER APPROX.BORING DEPTH cog BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED _('d YES,list specifications in comment section) <br /> ) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina a lations, and all applicable California State Laws. <br /> Signed x I Title/Companyd� <br /> Print Name /.f Dale <br /> S <br /> DEPARTMENT USE <br /> "ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: - �O -O <br /> Application Accepted By Date Issued �'l`/ 5 ,area C�6 <br /> Grout Inspection By Date Final Inspection ey fiq /_ <br /> Destruction Inspection By Date 1� <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> LPELCODES FEE INFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# pL')54�1l <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit o✓ Encr�;e00ent doc"� <br /> EHD 29-02-001 �� O O>L <br /> 9/30/2003 <br />