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�ol> uIts <br /> 'Nan Joaquin CountyCOP <br /> a.. G <br /> Environmental Health Department ITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> ` (209)468-3449 Fax: (209)468-3433 Web: www.co,sanjoaquin.ea.us/ehd UNIT IV <br /> er cjge� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 9-1915.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 1 (J a n Assessors lq'OZ ODS} <br /> WELL Location ( [ Go -! Cross Street ffwy 9 9 city ,l t Zip Ts�Parcel# <br /> PROPOwner TY� .J�Da , ! �t LSU CA dress �, 60Y_-A1,40-7 City , _Zip �o26 Phone# Q b5 3�7/°��I7 <br /> C-57 Contractor VC Address ��� 0!'10.�+3 fVL�CityZip Lic# 0 hone# a209 66/ I6lJt7 <br /> Consultant t Sub Cntr ,lCw_� Address City Lic# Phone# <br /> i <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# `i _ a OVER-BORE. DIAMETER <br /> LL# j a PRESSURE GROUT <br /> a"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING a HOLLOW STEM DIA.OF BOREHOLE,[,~Q MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DW- <br /> p EXTRACTION a AIR HAMMERID RIVEN CASING THICKNESS TYPE OF CASING: Q STEEL p PVC a OTHER: <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL'C"p TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> �]AIR SPARGE!OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING p HAND AUGER GROUT SPECIFICATIONS l2p , <br /> /n OTHER:_U OTHER APPROX.BORING DEPTH a BOL 1 TRAF IC BOX or 0 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 Or 'nances, Rules and Regulation and all applicable California StateXs. -,l <br /> Signed x TitlelCompany e— arms 7 <br /> Print Name ei Date U <br /> DEPARTMENT USE ONLY , <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 4 + <br /> WORK PLAN DATED: 61 DV B <br /> Application Accepted B A. Y+ Date Issued Area <br /> Grout Inspection Bye Date Final Inspection 3y to 3 <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# INVOICE <br /> 35oI 99.00 ' 99. 00 -10748 sR# 003 8883 <br /> C-57� WC=WAIVER— C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> F_HD 29-02-001 <br /> 9130/2002 <br />