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o (,;-San Joaquin County. <br /> _�� COPY <br /> Environmental Health Department APR 1 9 2004 SITE <br /> ` 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.co.sanjoacPA/RdMal F HEALTH UNIT IV <br /> RP PERfi01IT/cERVICES <br /> " <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 wild San <br /> —Joaquin County.Development Title,Chapter 9_1115.3_and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> FH zi 53-7(e Parcel# ?=, �0 - 2Z <br /> WELL Location I� a,s} 2 - 5.4!-99—+ Cross Street CitySr�c p 9 = <br /> PR OPE ` <br /> Owner +r�Rr,aT-�O. Address a/. City. Zip Y S Phone# <br /> '�T #_None#� +t� <br /> C-57 Contractor Addresszl $ Ci <br /> Consultant/Sub Cntr: ;) �nv�ronf�ew�l Address 0 Pity Co n Lic# Phone# 25' $ <br /> Y ,Township Range Section <br /> GIS Coordinates:X . <br /> WORK TO BE PERFORMED: <br /> i1 OTHE <br /> NEW WELL!BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, fESTRUCT'ON (choose ty ee below) <br /> VEBORE. DIAMETERQ SOIL BORING# PRFSRE GROUT <br /> 0 WELL# ROUT SPECIFICATIONS <br /> d*Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONI70RING FnUAIOR <br /> LLOW STEM DIA.OF BOREHOLI Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:_— <br /> EXTRACTION HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL []PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 1 --TREM)E TYPE TO BE USED: Q AUGERS a HOSE" <br /> []AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q YesQ No (NOTE: MAXI UM FREE-FALL DEPTH IS 30) <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q <br /> OTHER:_��Q OTHER APPROX.BORING DEPTH Q <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 Ordi es, R les an Regulations,and all applicable California State Laws. <br /> LO 6-0e <br /> Signed x <br /> Title/Company ;l�4i'uf�]'L. <br /> Print Name ! Date_ — <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I E• I Z�'`` S <br /> WORK PLAN DATED: I3 2®O <br />' Date Issued Are f�6`� ' <br /> Application Accepted By -� <br /> Grout Inspection By ate Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> F. PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> I' 56 INA (ob. r 125 _sR# <br /> C-57_ WC=WAIVER. C-57 Letter of Authorization to sign permit-•_Encroachment doc <br /> EHD 29-02-001 <br /> 9/30/2002 <br />