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as 1i r i <br /> 01; 0 <br /> 9n Joaquin County ,� �� SITEEnvironmental Health Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 AUG 0 9 2004MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: wwW.sjgov.or 0NMENT HEALTH UNIT IV <br /> gERMIT/SERVI <br /> -- NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE , <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 ith an <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location <br /> �i LM 1P'1 71 C`lLb , (J�g, Cross Street�rlot nh .City- Zip 25dj Parcel# t-1 ZZ <br /> PROPE(R_,T � ���,t rtNau (A-62obl 64!x-��cty`�Z�p��'one# 904' y7� 17`1( <br /> Owner DntlTiZld O\S Address /� Qmn c.U.o <br /> CYt�O� '' Address�"��MD� L �� City Cc YlC.� Zip Li 7 I Phone#ql 3A(1 9 <br /> C•57 Contractor �`''�'''" , ( -7(n <br /> � < AddressHII Old Ft=(uil� City�u v� Lic# Phone# fI�F <br /> Consultant/Sub Cntr , x�_ _ <br /> GIS Coordinates:X <br /> y.,TownshipRangC Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER`) p EER BORE.I (choose type below) <br /> DIIAMETER <br /> SOIL BORING# ) D PRESSURE GROUT <br /> .WELL# ��'' GROUT SPECIFICATIONS <br /> D•Other �f[l/`f �— G do /d'O y Ile <br /> COMMENTS:— <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS RO <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE_O0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSD FJ4°-�xjt�,a TYPE OF CASING: O STEEL ,` PVC 0 OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL us TREMIE TYPE TO BE USED: D AUGERS XIOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: WYes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING D HAND AUGER GROUT SPECIFICATIONS �r � p LTED TRAFFIC BOX or 0 STOVE PIPE <br /> D OTHER:_0 OTHER APPROX.BORING DEPTH F <br /> CONDUCTOR CASING PROPOSED (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 prepa d this applica . n and that the work will be done in accordance with San Joaquin <br /> County Ordinan Rules a d egulat' s, a all applicable California State Laws. <br /> Title/Company <br /> Signed x O D <br /> ������ Date Q <br /> Print Name �(JA/ <br /> DEPARTMENT U E ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> OV <br /> WORK PLAN DATED: ' j�' 60 <br /> - Date Issued �— � Q� D Area <br /> Application Accepted By Final Inspection By ate <br /> Grout Inspection By Date <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/BE <br /> Z10 <br /> # INVOICE <br /> Z10 491• ,41 � SR# <br /> C-57_ WC WAIVER_ C-57 Letter of Authorization to sign permi Encroachment doc� <br /> EHD 29-02-001 <br /> 9/302003 <br />