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RECENVIEC <br /> 7East <br /> San Joaquin County 0 guo FTonmental Health Department APR 1 9 2004 SITE <br /> eber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> 0jjP(209)468-3449Fax (209)468-3433 Web www co sari�oa�figi��1r HEAL1 H UNIT IV <br /> PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED \Z3 <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 wdl San <br /> Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> 1A _ Assessors <br /> WELL Location m k"t li? - .}tge-� Cross Street City Yac Zip -7!o Parcel# 2-3 3-3 2Z <br /> PROPEBTY ` <br /> Owner_'t'acj i t�r�aneAT,��O/. Address f LID��77 Nom,,�fM1.,� �o City Zip Y SPhone#1+115-8ZV- WeS <br /> C-57 Contractor U I QOIJ GX- Address`Iro Ad*" Cii _ # <br /> ' Consultant/Sub Cntr Sllaus FAvti>-bnJ K�ct l Address 11005 1�4.C�itauz+ :dy C°.ttonl(Q Lac# Phone# 5- <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 11 NEW WELL 1 BORING (CPT GEOPROBE HYDROPUNCH HAND-AUGER,OTHE DESTRUCTION (choose +below) <br /> a SOIL BORING# OVER-BORE DIAMETER A <br /> a WELL# ]]PRESSURE GROUT <br /> 11*Other GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> km ONITORING F[n]AIOR <br /> LLOW STEM DIA OF BOREHOLI� 0 MULTIPLE CASINGS [l MULTI-LEVEL WELL CASING DIA <br /> EXTRACTION HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING o STEEL []PVC 0 OTHER <br /> Q VAPOR []MUD ROTARY DEPTH OF GROUT SEAL -TREMIE TYPE TO BE USED ©AUGERS HOSE <br /> 41AIR SPARGEI OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED 0 Yes []No (NOTE MAXI UM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> []OTHER ©OTHER APPROX BORING DEPTH []BOLTED TRAFFIC BOX or []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 t have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordl es,;4anRegulatons,, O <br /> ind all applicable California State Laws <br /> ��Lo "'Sr/ <br /> Signed x Title/Company S!I"147y1d7La <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> rSITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued [_ Area Q p?q <br /> 1 Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ,rpt D lacy• 1—ti, sR# jo$ <br /> C-57 4 WCT WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 9/30/2002 <br />