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�an Joaquin County ��1'�',_I� v`� ' <br /> qDs6vl <br /> Environmental Health Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 AUG 0 9 2004MITIGATION <br /> �8 Ffftffl /1EN1 HEALTHUNIT IV <br /> (209)468-3449 Fax: (209)468-3433 Web_wwws ov.or n I PtRfvll i/SERVICNON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f <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 with San <br /> Joaquin County Development Title,Chapter 9-1115..3�andnd the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> Cil h-r-) 12(''iC a�Q ktCross Street City "1=Zip ySc3C� Parcel# 2Ll 2-Z <br /> WELL Location ( <br /> y `' II•tk o 17 9( <br /> PROPELRry7'3. �r �(-�\�10\S Address rr�a� (.i;.120�i(1�1C(L'�_CitY�JL- �ZID '�hone# ;,!0Q �-1�7n <br /> PWner J` NC ," 1' Qu)c!..�' r7 -0 (c9 <br /> Address 2�' -�r'lfC��-1 �- Ciry C'c'1ZipLIS� Li 7 I Phone# li �'�`) <br /> C-s7 Contractors-( � phone# PI�' 3�" ("" <br /> iQ-{II U'IdQA(Fi wilt Clty`�i i Lic# <br /> — Address - <br /> Consultant/Sub Cntr 5&C Section <br /> Township Range <br /> GIS Coordinates:X� 'Y�� <br /> WORK TO BE PERFORMED: ESTRUCTION (choosetyp elo 11� <br /> NEW WELL I BORING -AUGER,OTHER')(CPT,GEOPROSE,HYDROPUNCH,HAND VER-BORE. DIAMETER <br /> n SOIL BORING 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> a-Other <br /> COMMENTS: � n11 t)-Gr <br /> TYPE OF WELL INSTAL�TION TYPE CONSTRUCTION SPECIFICATIONS <br /> b <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE-0000 MULTIPbI,CASINGS 0 MULTI-LEVEL4 0L WELL CASING DIA: <br /> STEEL <br /> PC <br /> 0 EXTRACTION u AIR HAMMER/DRIVEN CASING THICKNESS0 Y�4�- '1-rvPE OTREM EI TYPE O BE USEED:V C U GERSOTHER:R V IOSE <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOT : MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING p HAND AUGER GROUT SPECIFICATIONS <br /> .�Y OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER: 0 OTHER APPROX.BORING DEPTH if YES,list specifications in comment section) <br /> CONDUCTOR CASING PROPOSED ( <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 ed this applica ' nand that the work will be done in accordance with San Joaquin 4 <br /> County Ordinan Rules a d egulat' s, a all applicable California State Laws. 31.��%�l�r�iff� <br /> Title/Company <br /> Signed x o <br /> _Date <br /> Print Name— <br /> DEPARTMENT Y <br /> DEPARTMENT USE <br /> as <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ioi630 O <br /> WORK PLAN DATED: <br /> Date Issued Area <br /> Application Accepted By1 ' Dale <br /> Date�Final Inspection By <br /> Grout Inspection By <br /> Date <br /> Destruction Inspection By <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DTE PSERMIIT/SERVICE REQUEST# INVOICE <br /> 29oz W� �i 13 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 9/302003 _ <br />