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Py <br /> • San Joaquin County ``J� V'� <br /> Environmental Health Department APR 1 9 2004 <br /> SITE <br /> 2 MITIGATION <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 9520�,�y��T H��L�N UNIT [V <br /> (209)468-3449 Fax (209)468-3433 Web www co san-loaWaLh W- IT tCs <br /> ' 3 NON-REFUNDABLE PERMIT>=XPiRES 1 YEAR FROM DATE ISS <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 wtA San <br /> T Joaquin County Development Title Chapter 9-1115 3 and the Standards of_San Joaquin County Erivironmental Health Department w <br /> Assessors <br /> il. Cit roc zip 453�10 Parcel# 233-3� - 2z <br /> WELL Location 10 >r use 12- ` S.tteeJ Cross Street E Y <br /> PROPE ,� City Zip gYlO.r_Phone#_`+/1S-8ZY- Y6 8 <br />' Owner ` - a Address �rif QrJ� <br /> C-57 Contractor Address <br /> ZI�o 1�TI4Si a �# �nne#�/V C�rP'a TIP <br /> e# <br /> Consultant/Sub Cntr: 1> W�nJ�rnn f wAddress <br /> rty�o o t.rc# Phon5- 8 <br /> GIS Coordinates X Y <br /> Township Range Secbon <br /> WORK TO BE PERFORMED <br /> p NEW WELL 1 BORING (CPT GEOPROBE HYDROPUNCH HAND-AUGER OT1iE OVER-BORE I DIIAM(ET R 8 -�elow) <br /> II SOIL BORING# 1]PRESSURE GROUT ' <br /> WELL# v GROUT SPECIFICATIONS <br /> 'Other <br /> ' COMMENTS <br /> TYPE OF WELL ItJSTALtAT10N TYPE CONSTRUCTION SPECIFICATIONS <br /> MULTIPLE CA5INGS l]MULTI-LEVEL WELL CASING DIA <br /> ONITORING OLLOW STEM DIA OF BOREHOL� i] <br /> AIR MAMMER/DRiVEN CASING THICKNESS TYPE OF CASING Q STEEL []PVC OTHER <br /> EXTRACTION U r TREMIE TYPE TO 13E USED Q AUGERS []HOSE <br /> []VAPOR 13 MUD ROTARY DEPTH OF GROUT SEAL <br /> 1R SPARGE/OZONE PUSH POINT(GP or CPT}GROUT SEAL PUMPED []Yes 0 do (NOTE MAXI UM FREE-FALL DEPTH IS 30'} <br /> INNISOlt BORING HAND AUGER GROUT SPECIFICATIONS <br /> {1 OTHER l]OTHER <br /> APPROX BORING DEPTH j]BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES list specifications in comment sechnn <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS RAGREEMENT R O P ENCROACHMENT PERMITS. <br /> REQUIRED <br /> 48 WORKING HOURS NOTICE <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� <br /> Title/Company S NrL <br /> Signed x <br /> Date cS <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued ` Area OJ <br /> Application Accepted By Final Inspection By Date <br /> Grout inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS_ <br /> iACCOUNTING ONLY AID# FAC# <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST INVOICE <br /> # <br /> SR# fob <br /> C_ ter of Authorization to Sign permit Encroachment doc <br /> EHD 29-02-Mi <br /> 9/30/2002 <br />