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, <br /> --San I Joaquin County <br /> 0 .� Environmental Health Department SITE <br /> I� I <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 <br /> MITIGATION <br /> (209)468-3449 Fax: (209)46$-3433 Web: www,co.san-',koa uin.ca. <br /> ., !� � us/ehd UNIT IV <br />' NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DALE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install <br /> Joaquin County Development Title,Chapter 9-1115.3 and the the work described. This application is made in compliance with San <br /> Standards of San Joaquin County Environmental Health Department. <br /> 'I I <br /> DWELL Location , Yt� ]I�Dross Street v! Assessors <br /> :PROPERTY t Q f ���. `�Q1t/Ecti City tl p ZIP Parcel# <br /> r Owner Address l a �rdL. !S 3? <br /> d �tY ip 9 05 Phone# <br /> 'C-57 Contractor ff�' C„�7 <br /> ���15Address �u City GrTI n@ Zip 9ySS3Lic# +Phone#9a2 31 3— �a�'v0 <br />! Consultant 1 Sub Cntr rnT F Address' q r { City I! F s ic# Phone# <br /> 63'-lnto <br /> GIS Coordinates:X h 1437.7545Y : tniIll.+{ 09 ,Township Range Section a2 <br /> WORK TO BE PERFORMED 'I j <br /> NEW WELL/BORING (CPT,GEOPRpBE, HYDROPWNCH,HAND-AUGER,OTHER') DESTRUCTION (choose type below) <br /> a SOIL BORING# 'I Il OVER-BORE. DIAMETER <br /> WELL# U3— v`i 1 Q PRESSURE GROUT <br /> Other v' GROUT SPECIFICATIONS <br /> COMMENTS: <br /> 4 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE [i MULTIPLECASINGSa MULTI-LEVEL WELL CASING DIA: _ <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASINdTHICKNESS SCI'( '10':' TYP1E1 OF CASING: ll STEEL )<PVC O OTHER: <br /> p VAPOR MUD ROTARY DEPTH OF GROUT SEAL=. �r; Yi TREMIE TYPE TO BE USED: UGERS a HOSE <br /> []AIR SPARGE(OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes€l�Vro ;[NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS me 11T i i' �o et i+t o wi> <br /> a OTHER: 11 OTHER APPROX.BORING DEPTH 3Q 3,'� 4�+- D BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 0"D (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 Ibe done in accordance with San Joaquin <br /> County Ord' , e d Re a ns,and all applicable California State Laws. y� <br /> (Signed x n� 'n Title/Compariy �/� 70ee;/'Ar' <br /> Print Name / Date :3/z 7►/� <br /> DEPARTMENT USE ONLY nf� �IIC�� D <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ln�L� Il <br /> WORK PLAN DATED: �� I '! <br /> ;` <br /> Application Accepted By - Date Issued � n i n inAGhIT W �N , <br /> Grout Inspection By Date l 0 Final Inspection By nrnn nrr rc�Be1`€� <br /> Destruction Inspection By Date } �� <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# 11: <br /> ,.{ FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> i <br /> sR# 373 <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 />