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Application Accepted By <br />Grout Inspection By Date <br />Destruction Inspection <br />COMMENTS! CONDITIONS: 04-1- LO(' <br />Date Issued <br />inal Inspection By <br />Date Area liF7 <br />Date <br />7o77_, cthc&--4-o . <br />WELL Locatiorl 'M <br />,an Joaquin County <br />ErtiiyiToinmental Health Department -I <br />li <br />1TE LL' <br />(209),m3145Fggwo9) 468-3433 Web: wwi,v.co.san-joaquin,c,A.usiehd 5 20u4 <br />3-04 East ebfe Avenue, 3rd Floor, Stockton, CA 95202 JLJN <br />: <br />M ITIGATION <br />UNIT IV <br /> <br />LTH <br />Ko41A.‘2-7-( i , 3siuo 4-)A irk}s•Liii Oe_ <br />PROPE <br />0-- <br />Owner s 04,Sly-ttc-6-) elite /Address Cityie— ZiXe2Xh„e# Oh 23 7 /54. (7 t Y <br />C-57 Contractor IN e -un ,ANress r c)"1-Z' City (L'21:1-'' V4Zip (-14671Lic#hone# 7v-7 37V 4,1SCX23 <br />Address • ied-eity&Y‘czi2-4.04.)c-# phone# 2,06 (-76ZoCNL Consultant/ Sub Cntr "617 <br />tNVIRONIVIET <br />ENVIRM AN,3 F.Ent.1:PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDPERMIT/SER1 /ICES <br />Application is hereby made to slia%J iTircikimpEis, permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin Oounty Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Cross Street <br />.7.1c,,L) city S'-frx_te......1.114) Assessors /1..1 __( <br /> Zip 1-1 Parcel# <br />GIS Coordinates: X , Y <br /> <br />, Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />Ei NEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />a SOIL BORING # <br />WELL # <br />1:1 *Other <br />COMMENTS: r-Af CLA--t-/ <br />itiols,,ESTRU CT I 0 N (choose typeg, <br />: E. DIAMETER <br />PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />CONSTRUCTION SPECIFICFIONS <br />DIA. OF BOREHOLEgi gMULTIPLE CASINGS ,j2KULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS /t/A- TYPE CF CASING: 0 STEEL a PVC 0 OTHER: <br />DEPTH OF GROUT SEAL /e.5 F1REMIE TYPE TO BE USED: UGERS 0 HOSE <br />: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 OTHER: 9 OTHER APPROX. BORING DEPTH <br /> <br />0 BOLTED TRAFFIC BOX or 9 STOVE PIPE <br /> <br />CONDUCTOR CA G PROPOSED (if YES, list specifippons in comment section) <br />COM%IpITS: 416-114/7-e- ()Lilt-- /7) /0 -- el7/— • <br />PAAAT IpA-tS SLAAX- elV'CA.44 far 5 X65 <br />NOTE: OFFSIT BORINGS RE-:QUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />)4-110NITORING j6i0LLCW STEM <br /> <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGEI OZONE 0 PUSH POINT (GP or CPT1GROUT SEAL PUMPED: (es No NOT <br />9 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <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 Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company <br />Print Name ate <br />DEPARTMENT USE ONLY <br />&// 0Y- A(E.— <br />SITE MAP IN UNIT IV FILE, 7DREiSS: <br />WORK PLAN DATED: <br />ACCOUNTING ONLY: <br />I <br />AID# FACti <br />___ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />902_ o - (vo <br /> .15-,zizq 6/4<__ ‘,(Ls-1/4,9 sR# no c---x 1 <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />El-ID 29-02-001 <br />9/30/2002