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ti o � <br /> ' LJ San Joaquin County RECIE v7IJGIPT( <br /> Environmental Health Department APS 1 2004 SITE <br /> ' 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> ((209)1468-3449 Fax: (209)468-3433 Web www co sari boa, &.&WU I HEALTH UNIT IV <br /> ICo PERNITSERVICES <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 w San <br /> — Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County En�nronmental Health Department <br /> ' -- - - __---- — -i----Assessors—_-----_----- <br /> WELL Location 10 I;0.S} Z?� $�r�e' Cross Street Cary kacZp "7� 22- <br /> PROerPE <br /> ' <br /> Own <br /> a� T Addressj_q() N:e—AA ada p _Cdy l�ZiP�0Phone�#y`+►fS,�-$2y Y88�8�/Q'��j�J� <br /> C-57Contractor <br /> ' Consultant/Sub Cntr 5111%w Fflv�►-0-%MP-!j- Address 9005 !?4 Chk,-, ityG�Lrc# Phone# $- <br /> GIS Coordmates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> Q NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH HAND-AUGER OTHE DESTRUCTION (choose elow) <br /> ]]SOIL BORING# OVER-BORE DIAMETER <br /> 1]WELL# 1]PRESSURE GROUT <br /> []`Other GROUT•SPECIFICATIONS <br /> COMMENTS <br /> ' TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING OLLOW STEM DIA OF BOREHOLKLI-1-- Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA <br /> 41 EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING []STEEL Q PVC [)OTHER <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL -TREMIE TYPE TO BE USED Q AUGERS Q HOSE <br /> 0IR SPARGE/OZONE (]PUSH POINT(GP or CPT)GROUT SEAT_PUMPED Q Yes p•Id`o (NOTE. MAXI UM FREE-FALL DEPTH IS 30') <br /> OIL BORING Q HAND AUGER GROUT SPECIFICATIONS - <br /> Q OTHER fl OTHER APPROX BORING DEPTH Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES Gst 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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />' CountyOrdi es, R es an Regulations, and all applicable California State Laws. <br /> Signed x Title/Company S elebLo&6yjl <br /> Print Name4 l Date �����(). <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 10 E. ISS to- <br /> WORK PLAN DATED: <br /> Application Accepted By-- �� Date Issued —u"fl Area 0 D u ' <br />' Grout Inspection By Date Final Inspection By Date <br /> De-struebon Inspection By Date <br /> COMMENTS l CONDITIONS <br /> ACCOUNTING ONLY AID# FAC# <br /> E CODES FEE INFO AMOUNT REMITTED CHECKS REC-D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 1 50z D 66- ' 125 - �.w` '�_� SR# ��' <br /> C-57 WC _WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />' EHD 29-02-M <br /> 9/3012002 <br />