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0 ouIH <br /> �z o n Joaquin County <br /> Environmental Health Departmen �,/ s, ��' <br /> SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> (209)468-3449 Fax: ) JUN 0 1 2004 MITIGATION <br /> \4 :...,..:.. s (209 468-3433 Web: www,cd,san joaquin.ca.us/ehd UNIT IV <br /> \rFpHN <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEARFROM DATE IS uNVIRONMENT HE' Tu <br /> Application is hereby made to San Joaquin county for a permit to construct and/or install the work described. RMIap�ERVn is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Slander(s of San Joaquin County Environmental Health Department. <br /> D 4- w �e r Nie lA fp,(,e�(r <br /> WELL Location c f r �.} <br /> � ` Y Cross Street_.5�_ t. City -v ,� 9,�azParcAssel# 3 G <br /> PROPERTY U^ka rl (J.t!�V. '�-t "� Zip Parcel# <br /> Owner Address <br /> 1' City Zip Phone# <br /> C-57 Contractor V�rJr CC���� jj —� <br /> Address S Cit J.Y Lt.,J <br /> Consultant/Sub Cntr I ' ',� qn - y gyp'-if`�o hone# <br /> j4ddress W ..J <br /> GIS Coordinates:X=_ Y _ ity A Lic# —Phone#�Z � d- 7r n r <br /> Township Range__ Section <br /> W RK TO BE PERFORMED: -- <br /> EW�1�lELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER* <br /> SOIL BORING# ) Q DESTRUCTION (choose type below) <br /> WELL# 0 OVER-BORE. DIAMETER <br /> a`Other - 0 PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPEC FICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE '�77 <br /> EXTRACTION _n 0 MULTIPLE CASINGS Il MULTI-LEVEL WELL CASING DIA:_ <br /> AIR ROTARY <br /> /DRIVEN CASING THICKNESS <br /> p VAPOR 0 MUD ROTARY TYPE OF CASING: 0 STEEL 0 PVC Q OTHER: <br /> DEPTH OF GROUT SEA i ��4 t TREMIE TYPE TO BE USED: <br /> ```p��/AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: �a Yes j AUGERS HOSE <br /> 7CSOIL BORING �HAND AUGER 0 No (NOTE: MAXIMUM U FREE-FAL D PTH IS 30') <br /> cb GROUT SPECIFICATIONS (L rI� / <br /> ] THER: U OTHER APPROX.BORING DEPTH ` P 3 S. <br /> CONDUCTOR CASING PROPOSED LTED TRAFFIC BOX or STOVE PIPE <br /> COMMENTS: (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certi tha a prepared this application and that the work will bedone in actor nce with San Joaquin <br /> :ounty Or ' nc le nd Regulations, and all applicable California Ste a Law <br /> Signed x <br /> Title/Company 7 <br /> TIint Name SIU ` V7�r lgn/'rc¢5 <br /> Date J 7A p <br /> DEPARTMENT USE ONLY <br /> iITE MAP IN UNIT IV FILE, ADDRESS: <br /> VORK PLAN DATED: <br /> ,pplication Accepted By (� <br /> Trout Inspection By Date Issued ?. zo o - <br /> Date 7---��rea <br /> Date <br /> restruction Inspection Final Inspection By Date <br /> :OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE 'D DATE PERMIT f SERVICE REQUEST# INVOICE <br /> 2 01 $9 op 2 cf SR# 3 $ 2 55 <br /> -57_ WC--WAIVER <br /> HD 29-02-001 C-57 Letter of Autho zo ' sign permit_ Encroachment doc <br /> '30/2002 _ -- <br />