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Lit • • <br /> a>° •coa Satt;Joaquin County <br /> y Environmental Health Department <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 SITE <br /> c `• (209)468-3449 Fax:(209)468-33H433 : www.sjgov.org/ehd MITIGATION <br /> �rF°t=� �� mitPA 40 UNIT IV <br /> pplication <br /> NON-REFUND&" UM TAY <br /> Application is hereby made to San Joaquin County fWq�i Q�( R FROM DATE ISSUED <br /> Joaquin County Development Title,Chapter oust 5.3'a d tfie"010>ad s1a SanITIJ Joaquin Il the wornty k described This <br /> Health application <br /> is made in compliance with San <br /> WELL Location ft)7 F Itf�t„f j1,, <br /> Cross Street 1�'�� .X Q� Assessors <br /> PROPERTY City �`� +�^ Zip Lc- Parcel# 03•I Oo �'ci <br /> Owner Er%I- 6;, ra Address 140 k.V k L Io <br /> C-57Contractor 6 T-'5ifc aL� City=- — ZIP 5ZIS Phone# 05 q -Zg y—p <br /> .S� 4f ___Address CIty �o�f;ro�ZIp 4Y5S Lic#6 0 <br /> Consultant/Sub Cntr AG-E — `L� hone#/4zsl BIZ-sem <br /> Atldress <br /> ty Lic# Zz? Phone# Zoq - �� <br /> GIS Coordinates:X_— Y <br /> Township—Range Section <br /> WORK TO BE PERFORMED: <br /> gl EW WELL/BORINGCPT Z PROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type w) <br /> $'S`OIL BORING# <br /> 0 WELL# 0 OVER-BORE. DIAMETER <br /> p Other 0 PRESSURE GROUT <br /> COMMENTS I GROUT SPECIFICATIONS <br /> o� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE Z' <br /> 0 EXTRACTION 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> Q AIR HAMMER/DRIVEN CASING THICKNESS.—��TYPE OF CASING: Q STEEL PVC p OTHER: <br /> �Q�MUD ROTARY DEPTH OF GROUT SEAL ' ' <br /> Q AIR SPARGE/OZONE 11ruSH POINT(GP or�GROUT SEAL PUMPED: Yes TREMIE TYPE TO BE USED: R<UUGERS a HOSE <br /> 0 SOIL BORING 0 HAND AUGER 0 g Ido (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> GROUT SPECIFICATIONS _ /II {. <br /> 0 OTHER:- - - -- p-OTHER- - - - _ -APPROX.BORING-DEPT H lon _ U <br /> Q 13OLTED-TRAFFIC BOX or -0 STOVEPIPE - <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 I have prepared this application and that the Work will be done in accordance with San J ui <br /> County Ordinances, R les and Regulations, and all applicable California State Laws. <br /> Signed xD �� <br /> �� Title/Company_ ` ��{ �'. to •y� Arm <br /> Print N6rhe �( �� <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ±(o I <br /> WORK PLAN DATED: SJ }I D b <br /> Application Accepted By__� G <br /> Grout Inspection By_�� Date tt Lz 0 Date Issued it I I }�p,(� Area <br /> Destruction Inspection By Final Inspection <br /> Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# <br /> .;� REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> L19933 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sin ermit✓ <br /> EHD 29-02-001 9 p Encroachment doc <br /> 6/22/04 <br />