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San Joaquin County <br />2k` ? Environmental Health Department <br />i `'` 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />\(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />-0 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location 5 4 G tZ 4NT <br />6 lu k fLA Cross Street �h Y (jLlEdy <br />Assessors <br />"Tf-A y Zip 3 7 k- Parcel# -Z-Z3 -30 O� <br />PROPEPTY <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL *'PVC 0 OTHER: <br />CHECK # <br />0 Vf�OR 0 MUD ROTARY DEPTH OF GROUT SEAL 13 TREMIE TYPE TO BE USED: J'AUGERS 0 HOSE <br />Owner ? 4 0J M S't ,u l- i { <br />AddressS A- NL tU <br />City <br />Zip Phone# I - q - e73 -3 f/,6 <br />C-57 Contractor �{ zyA S r ,cam <br />Address 2--,rW - <br />a ov <br />IZ u- Pl,'J'Jr4 1 cCity q-1t� VtLt Clip 4t(•1 f-ULic# Phone# 17 C4 2-a - 93'q / <br />Consultant/ Sub Cntr *L11'* SC t E _Address <br />Sit X", fCr <br />CityL ic# Phone# <br />GIS Coordinates: X =io H5 fy.f <br />, Y i i/` LG - y.ycc <br />,Township � S' <br />Range S 1. Section �c <br />WORK TO BE PERFORMED: <br />EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') H DESTRUCTION (choose type below) `/ r <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER _ 1 <br />H WELL # 0 PRESSURE GROUT �1 <br />"Other 61-o r+ b_ .S P tZ i, -w GROUT SPECIFICATIONS <br />COMMENTS: 1-C7 P_ j; J71_ kCe D,t- M A- t_ 20 tj, —J' Pfir, 6-10 G (-JF C. L C S - 2 C <br />C,. <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />FAC# <br />)/ <br />0 MONITORING WOLLOW STEM DIA. OF BOREHOLE 5' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />PE CODES <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL *'PVC 0 OTHER: <br />CHECK # <br />0 Vf�OR 0 MUD ROTARY DEPTH OF GROUT SEAL 13 TREMIE TYPE TO BE USED: J'AUGERS 0 HOSE <br />-� <br />IR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes WNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />.V <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS C . yn-A . k- <br />H OTHER:_0 OTHER APPROX. BORING DEPTH I {}'BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED r (if YES, list specifications in comment section) <br />COMMENTS. TC ILS PC -A -t -f I%/fM1164EA 62-cs/JE- liP LL OS -2- <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 Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x C/ - Title/CompanJ��e,-e-2 cam- <br />Print Name U&.- - Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED:: <br />-Z Z <br />Application Accepted By Date Issued O Are <br />Grout Inspection By Date Final Inspection By Date 161 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE ERVICE REQ T # <br />INVOICE <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroac <br />EHD 29-02-001 <br />9/30/2003 <br />