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' 03/31/2006 10:29 2094683433 END 0 <br /> PAGE 02 <br /> San Joaquin County <br /> T rN Environmental Health Department <br /> 304,E46t Weber Avenue, 3rd Floor,Stockton,CA 95202 SITE <br /> ' 2 MITIGATION <br /> t�ryOf, <br /> ( 09)468-3449 Pax:(209}468-3433 Web:www.sjgov.org/ehd <br /> 6 r 'A&.1 P1>9R 27 �P?t1=Oil Permit ApplicationAPP,lUNIT IV <br /> 5 A!FFff•' LE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ' Josquinn Cois reby�Lf .E , ,for a permit to construct and/or install me work descrIW. This aPPliptlOn is made h comPlianoe with San <br /> Joaquin Cu Deal ellllt' ,,Lap 'btf E*'T and m0 ytandardslof Son Joaquin County Environmental Health DepaRmer$, <br /> ' wBLL lAeadon� 1 5 M��e"nt„'� Cross Slmet i4 - 01,, 1^1' � �5 s5eaaore <br /> OwnePROPr Ct'{p7 ----- p q� aral#_ <br /> — 4 �' Address IdUI "'r �.IIT7Bar G,;,/•',..�.,,nr�Zlp Pnomx !t(O.�X.(I.(.,1et—t <br /> ' C47 Contractor Address ."5�Y-owxurz . <br /> Cal' Zi Udt�GPtpnelr <br /> Cenenitaort/ rBnO ✓t ,� Address 7 x IpE ✓ C ' �4dPlmnas9l , '-1$1 rz�„ <br /> GIs Coordinates:X <br /> Y--�„Townshp Range Section <br /> WORK TO BE PER#ORIYED <br /> 0 MEN J BORING (CPT.GEOPROBE,HYDROPUNCH,HAND.AU <br /> 0 SOIL BORING# GER,OTXER') �( ; $f t„:'CFS +N (Ohpose type below) <br /> 0 WELL# D OVER-EIRE, DIAMETER_ <br /> ' 9 VMer 0 PRESSURE GROUT. <br /> COMMENT8:_. +41I- GROUT SPECIFICATIONS <br /> t'"� fiy�-`+7 `�a'S �'Yi' t7rLri ��()yrs (x�'t— S �/lbb lNIfe21//rL. 'Ib$E +lf�Gi7 f12s7: <br /> ' LL !N$TALLATiON TYPB ggN_at'41JOno NRPECLUATIONS <br /> MONITORING 0 HOLLOW STEM DIA OF BOREHOLE <br /> 0 EXTRACTION0 MULTIPLE CASINGS U MULTI-LEVEL MLL CASING DIA-- <br /> 11 _ <br /> AIR HAMMERIDRIVEN CASA ING THICKNESS - TYPE OF CASING: U STEEL U PVC n OTHER: <br /> ' TYPETO BE USED: <br /> 0 VAPOR n MUD ROTARY DEPTH OF GROUT SEPI D AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED-. U Ves 0 No (NOTE'EMA7(IMUM FREE-FALL DEPTH IHME <br /> S)M <br /> 0 SOIL IS 0 HAND AUGER GROUT SPECIFICATIONS30) <br /> O OTHER: n OTHER APPROX.BORING DEPTH <br /> n BOLTED TRAFFIC BOX or g STOVE PIPE' <br /> ' COMMENTS: CONDUCTOR CASING PROPOSED (if YES,IIstsPacificetlons in comment seotion) <br /> NOTE; OFFSITE @ORINO$REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> ' 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances, Rulegulations,and all applicable Callfomla State Laws, <br /> ' SipnedxTism omparly ,I->W T QI�T MbWly <br /> Print Naei �41111's <br /> -7 Date 3JZy—a4- <br /> ' DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS; <br /> WORK PLAN DATED: 0 <br /> ' Groutaaon Accepted By ,1�+��[ Datalssup LZ �_ bn-� <br /> Applcalla Acca to 4 Qhs ArEa�..� <br /> Date Flnal lnspeclion By_. Date <br /> Destruofidn Ins action B Date <br /> ' COMMF-alt8l CONDrtIONS• /�i N — f f � �� <br /> ACCOUNTING ONLY: AID# " ri- <br /> FAC# <br /> PECOGES FEEINFO AMOUNTREMITTED CHECK# RECD BY DATE PERMIT!SERVICE REQUEST* INVOICE <br /> C-l57 I <br /> c-57_ we war <br /> a�IDzaoz-0ol <br /> R-- atter of AuThditizafion to sign Permit_,,,Encroachment doe„ -- <br /> ' <br /> wazroa <br />