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D V <br /> i San Joaquin County W EC E Nj E <br /> Environmental Health Department APR 1 9 2004 SITE <br />' 304 Fast Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax (209)468-3433 Web www-co sari-joacWFttL -3I HEALTH UNIT IV <br /> PERMIT/1SERVICES <br />' L Fa � 3 <br /> NON-REFUNDABLE PERMIT EXPIRES'1 YEAR FROM DATE ISSUED <br /> ounty for a permit to construct and/or install the work described This application is made in compliance wag San <br /> Application is hereby made to San Joaquin C <br /> — 11$3 and the Standards of San Joaquin County�n+nronmenta!Health Department <br /> Joaquin County Development Title,Chapter a <br /> Assessors <br /> WELL Location 1012 6 } 12 Ih cross Street l <br /> Gta <br /> tyt Zip 5 ?(o Parcel# 233-3 - 22 <br /> PROPE TAddress City Zip s{ sPhone# `SIS- 2yr.�$B�Q'��I <br /> ro � + <br /> C-57 COntractOr - ---Ass <br /> Consultant I Sub Cntr 5� <br /> £hvirpnpAQw}af Address o - ity�� L}c# Phone# $� 8 <br /> GIS Coordinates X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED <br /> U NEW WELL t BORING (CPT,GEOPROBE,HYDROPUNCH HAND-AUGER,OTHE ADE ST BORE RUCTIO <br /> D(ch000se a Blow) <br /> ETER <br /> (I SOIL BORING# -0 PRESSURE GROUT - <br /> 1]WELL# GROUT SPECIFICATIONS <br /> (}'Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITQRING OLLOW STEM DIPS OF BOREHOL�1-- MULTIPLE CASINGS {]MULTI-LEVEL WELL CASING DIA <br /> EXTRACTION (]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING (]STEEL []PVC II OTHER <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED Q AUGERS Q HOSE <br /> IR SPARGEI OZONE {]PUSH POINT(GP or CPT)GROUT SEAL PUMPED U Yes (]No (NOTE MAXI UM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING (]HAND AUGER GROUT SPECIFICATIONS <br /> OTHER_ APPROX BORING DEPTH Q BOLTED TRAFFIC BOX or (]STOVE PIPE <br /> (]OTHER_ if YES,lists ecirications in comment section) <br /> CONDUCTOR CASING PROPOSED ( p <br /> COMMENTS <br /> NOTE. OFFSITE BORINGS REQUIRE S ANCESSAGu REMERtOPEN ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS REQUIRED <br /> TIONS <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 es an Regulations, and all applicable California State Laws ��vl�axx <br /> TiUelCompany Sdpiv1 d7L eeb 1-6 G <br /> Signed x <br /> Date --�— <br /> Print Name ff <br /> %# <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I E• 12`~` S <br /> LOP <br /> iWORK PIAN DATED. <br /> Date Issued <br /> ' Application Accepted By Dale <br /> Inspection By <br /> Grout Inspection By <br /> pate Final <br /> Date <br /> Destruction Inspection By <br /> COMMENTS 1 CONDITIONS <br /> ACCOUNTING ONLY AED# +FAC#PE CODS FEE INFO AMOUNT REMITTED CHECK 9D 8Y DATELPERMIT SERVICEZe- ;ST# INVOICE <br /> r 2 W15 (a(�. 1215--T <br /> ( <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 9/30!2062 <br />