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JUN-22-2004. 15:11 j- ,. N6H,IA P,:02/05 <br /> 0010 sjui2quitii l.UUII1.y <br /> En �nmental Health Departmentil T SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 <br /> MITIGATION <br /> (209)465-3449 Fax: (209)468-3433'Web:www.sigov.org/ehd <br /> UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the Work described. This application is made in compliance with Sar <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WI:LLLvcativn rossSfreet tu1a11er �,CitySt&IrLL _Zip Paroel# <br /> PROPERTY <br /> Owner-$iACtl Cr;I P.jr& !•tC1f,�.US Address;,rw i?ai�1nl; s.Av cif . Cei�a v`r� p�' [I}Phone r�fii La�S� �7(►s <br /> C-57Contractor �� 'tIM OA Addres5rl156 11 City: r}►ALZZip553L1 <br /> Consultant ISub CntrCfL*%kby"V. j&KIeklj;L1Wi0ddress�� 1N5 CitySG;.G Lic# phone# ,►t` -.� 6 <br /> GES Coordinates,X ,Y _ ,Township __ Range Section____ <br /> WORK TO BE PERF611MFl3• l <br /> p NEW WELL 1 BORING (CPT,GEOPROB5.HYDROPU NCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> [I SOIL BORING# F]OVER-BONE. DIAMETER,... <br /> Il WELL# WRESSURE GROUT <br /> n*Other _- - _— GROUT SPECIFICATIONS Vel 4AYLa ], W <br /> COMMENTS: G�Wv c> &Uo� I�Gti. IZ`I fAX- i ! �. ui i' Ea•S s i% ; <br /> a.• o <br /> M.I:.OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [i MONITORING 11 HOLLOW STEN! DLA.OF BOREHOLE []MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: <br /> [I EXTRACTION l]AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING: []STEEL Q PVC []OTHER: <br /> []VAPOR l]MUD ROTARY DEPTH OF GROUT SEAL_ TREMIE TYPE TO BE USED: Q AUGERS d HOSE.- <br /> []AIR SPARGE/OZONE []PUSH POINT(GP or CPT)( ROUT SE=AL PUMPED- .G Yes [1N9 (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING []HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:___ _ D OTHER APPROX.BORING DEPTH I]BOLTED TRAFFIC BOX or I1 STOVE PIPE l <br /> CONDUCTOR CASING PROPOSED _(if YES,fist specifications in comment section,'. ] <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 be done in accordance with San Joaquin <br /> County O es, R ls and Regulations,and all applicable California State X/7 14 <br /> Laws, <br /> Signed x x Titie/Carnpany de Iibmb of;cts. r"V j r,0;,]iyeet,+- aof G4 <br /> Print Name j1Y1� hL C� ri <br />� Date V k-itiL IT , - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-ADDRESS: _ <br /> WORK PLAN DATED: <br /> ApptiC8110M Accepted BY C1t/-1 #>ate Issued . Area <br /> Grout Inspection By _Date__. Final Inspection ByDam z- <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST 0 INVOICE <br /> SR# J?r�5a <br /> C-57 WC�-WAIVER C-57 Letter of Authorization to sign permit—l=ncraochrnertt doc. <br /> EHD 29.02-001 <br /> 9/30/2003 <br /> i <br />