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'SELL r-ERMIT APPLICATION FO>evI SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4pplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> H )ELL Location �57 du. 5 /t7,Q� Cross Street 601A;'- /L City .5k Zip Parcel# <br /> -IROPERTY Owner/1(dri''?h i fP-LYE f JT4 G aAddress l0!� 14 S O 5T _City L4 LZipy-9-K Phon L-17'l-204 <br /> 57 Contracto ?L� 7 1 Address 1� 2 0j tC LII C Cit74—Zip9SLic#�1151 U P h o n lb 63 1 9 <br /> :onsultant/Sub CntrC >_A Address-6''���f� ttt kD City DC�[�G l�Lic#, x,72 Phone <br /> 31S Coordinates:X Y ,Township Range Section <br /> NORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") DESTRUCTION(choose type below) <br /> 'SOIL BORING# / 0 OVER-BORE <br /> WELL# 2 0 PRESSURE GROUT <br /> Other: Grout Specifications: , <br /> COMMENTS <br /> 'YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XMONITORING ,tlIOLLOW STEM DIA.OF BOREHOLE R X'"MULTIPLE CASINGS?o MULTI-LEVEL?a WELL CASING DIA: <br /> ]EXTRACTION 11 AIR HAMMERIDRIVEN CASING THICKNESSs 1.2 YPE OF CASING: a STEEL WPVC 8 OTHER: <br /> ]VAPOR []MUD ROTARY DEPTH OF GROUT SEAL f j i 9-0 " TREMIE TYPE TO'BE USED: AUGERS p HOSE <br /> ]AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL PUMPED: 9,1res 0 No (NOTE: MAXIMUM FREE-/FALL DEPTH IS 301) <br /> SOIL BORING o HAND AUGER GROUT SPECIFICATIONS: OIV-fk-GQ c:'��- 94W C�4ri I 1h 0 <br /> ]OTHER: []OTHER APPROX.BORING DEPTH ]VOL7ED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?_11/L•_(if YES,list specifications here): <br /> 'COMMENTS: r C.u1 I I S h v S/ 4 �'_t!�P C O/t �i DY!°`c, GLd"f U r``i('lam. a 4.- t->t .r <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> Coun Ordinances, Rules and Regulations, aid all applicable California State Laws. ,( <br /> Signedx TiUelCompany �E'.A1DC,t.S{- / YttyAVv�-Q �e <br /> Print Name 1 )q 1'1 1 e 1 K Ol 1 by' 6&C k Date 9 I b I (7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADRE S: w ' 3.C b 54bC <br /> WORK PLAN DATED: L+ 10 <br /> Application Accepted By / r l ' Date Issued ✓ Area <br /> Grout Inspection By Date Final Inspection By Date L <br /> Destruction Inspection By, Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350 1 I 2J /eb b5 1 3 55995 <br /> C-57 WC=WAIVER C-57 Letter of Aut arizotion to sign permit Encroachment doc 8/29/02 <br />