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06/26/2006 10:42 20946834 EHD7 � PAGE 02 <br /> Ij C L <br /> San Joaquin County j+.; � 4 g 2066 <br /> ]Environmental Health De ar SITE <br /> 304 East Weber Avcnue,3rd Floor, Stockton, /SER ICB MITIGATION <br /> �P���/SERVICES <br /> (209)468-3449 Fax:(209)468.3433 Web:www:co.sanjoaquin.ca.us/ehd UNIT IV <br /> c.Pba - <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County fora permit to construct andfor install the work described. This application is made In wmpriance with San <br /> Joaquin County Development Tiille,Chapter 9.1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Ra `I' Co-4 Assessors <br /> WELL Location t-U EV APTC0015WG b)?IVF Cross Street-1306N£ Mi w City SToCiGTT3h1 Zlp q5w3tParcel# ,� ,k•t <br /> PROPSt�TY <br /> Owner N027 OF STOCLM..N Address 22s1 W WaS `r.r> 11 City S('d1e(1.�9� ZtpI203 Phone# <br /> G47 CcntraCffl­,6,WMW Dt-1 Add ss_ 5.>`a'4'V9,9-. 24).4�-n CilykbylsrA ZjpR4S:fl Irc#Y9nM Phone#_ ;4tp7— 3�_y3 cr;. <br /> Consultant/Sub Cntr F_f2S Tnf Address Z-12k N y . CFIk7&42&- #k'9942o phone# 9't�) 3f'-lho� <br /> GIS Coordinates:X_Y ,Township f d Range Section <br /> WORK TO BE PERFORMED: <br /> O NEW WELL f BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) "ESTRUCTION (choose type below) <br /> n SOILBORIN5# DOVER-BORE DIAMETER <br /> n WELL# &PRESSURE GROUT ,L <br /> n-Othor GROUT SPECIFICATIONS`YZA onaaw r, <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING U HOLLOW STEM DIA.OF BOREHOLE n MULTIPLE CASINGS n MULTI-LEVEL WELL CASINO DIA: <br /> n EXTRACTION Il AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL n PVC n OTHER <br /> U VAPOR n MUD NOTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED- p AUGERS a HOSE <br /> I]AIR SPARGE!OZONE n PUSH POINT(GP or CPT)GROUTSEAL PUMPED: n Yes p No{NOTE: MAXIMUM FREE-PALL DEPTH 1830') <br /> O SOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS <br /> n OTHER: Q OTHER APPROX.BORING DEPTH n BOLTED TRAFFIC BOX or n STOVE PIPE <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 prepared this application and that the work will be done in accordance with San Joaquin <br /> County ordinancce��// l�iy�t,ts, Rules and Regulations,and all applicable California Staatte�Laws. <br /> Signed /vcOr4 1'.(A—'rc Tide/Company ✓�(il—Tl-Q�-/il.A�t, <br /> Print Name /I o ti A m (.' n is TTFi U oaie_d� La 6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WO RK PLAN DATED: <br /> �� <br /> Application Accepted By .Date Issued D Area 4 q~/ <br /> Grout Inspection By Date Final Inspection By Dalo <br /> Destruction Inspection By Date b to <br /> COMMENTS/CONDITIONS: V"/-Z7..V a— IA1 2-21 titLtJ'5 4,4 t ave4, +t.0 <br /> ACCOUNTING ONLY: AID# F <br /> PECODE$ I FEEINFO AMOUNTREMITTED CHECKS REC'DBY DATE PERMITISERVICE REQUEST# INVOICE <br /> � oL �` toy ,L< <br /> G-57 WCC WAIVER, C-57 Letter of Authorizat(on to sign permit_-,Encroachment dopL <br /> ESID 29-02-001 <br /> 9130 2002 <br />