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02/22/2006 10:15 20946B3433 EHD PAGE 03 <br />Satz Joaquin County <br />-En vlronmen-tal Health Department SITE <br />304 least Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468.3449 Fax: '(209) 468-3433 Web: www;e0.San-joc11quin.ca.us/ehd UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAI? FROM DATE ISSUED <br />ApPlloalion le hereby made to San Joaquin County fora permit to construct and/or Install the Werk described. This application Is made In compliance with San <br />Joaquin County Development Title, Chaplat J-1146.3 and the Siandard9 of San Joaquin County Environmental Health Department. <br />WELL. Locotior kl,,1 r41% k c /t tj � f`- ` Cross 8TtUD) -{ Ci � Assessors <br />Ur--�-. (y Zip ZO Parcel# Z ' 03O -Q <br />PROPERTY <br />OwnelTlc(} a-4- 4vi-k 4 <br />_ 'k Rg44.0244 4, <br />0.57 Contractor?—esa226 .,.t L5!-- c.Address T— <br />Cily .off en •Zpp Si��-19#/ Phone#S73 0 -CCS -Z -1 Lc.1 <br />sultant /Sub Cntr i*s+ 1(at' <br />(: (� ,,1e(. Ar <br />Con <br />Address t Z l A, (R cv.; � City � -� Llde 2Ei � I`SPhcneal_"1t 43%,' (SCD <br />abtn <br />019 Coordinales: X Y Y, Township Range Section— <br />WOR <br />RK TO BE PERFORMED: <br />IEW•WELL / BORING (CPT, GEOPROBE, HYAROPUNCH, HAND -AUGER, OTHER`) D DESTRUCTION (choose type below) <br />I 0 SOIL BORING 0 d OVERBORE. DIAMETER <br />j]'Othor D PRESSURE GROUT <br />, GROUTSPECIFICTIONS <br />COMMENTS: n-7 <br />— i _ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />`Q�MONITORING p HOLLOW STEM DIA. OF BOREHOLE, -'L p MULTIPLE CASINGS 0 MULTI-LEVEI, WELL CASING DIA: <br />/0 <br />`EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS_1 ` TYPE OF CASING: D SYEEL�VC BOTHER; <br />U VAPOR D MUD i2OTARY DEPTH OF GROUT SEAL��•TREMIE TYPE TO BE U FD: D AUGERS HOSE <br />D AIR SPARGE/ QZONEPUSH POINT (GP or CPT)GROUTSEAI, PUMPED: ayes' 0 '(NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />Q SOIL BORING 0 HAND AUGER OROUT SPECIFICATIONS 1- (. 4 ,, + <br />D OTHER: D OTHER APPROX. BORING DEF?H_'2 C> --K D BOLTED TRAFFIC BOX or STOVE PIPE <br />CONDUCTOR CASING PROPOSED (If Yes, Ilst speciflcatlons in comment section) <br />COMMENTS; T: et t_ ,,,t a S e d <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 donD in accordance with San Joaquin <br />Colin"ordlnancea, ft�los a eg f tions, and ail applicable California State Laws. <br />SiSigned x <br />� ` r• •.v.,,. <br />D Title/Company ; 1_ % <br />Print <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:. <br />WORK PLAN DATED: <br />Application Accepted B� <br />Grout Inspection By <br />Dastruction Ins ectlon By Date <br />COMMENTS /CONDITIONS <br />ACCOUNTING ONLY: AID# <br />PECODES I FEEINFO I AMOUNTREMITTED I CH8CK# <br />C-57,_ WC_W/A1VER_ <br />EHD 29-02.001 <br />9/30/2002 <br />Z -S l b <br />I Inspection By Dato <br />F <br />REC-D BY I DATE <br />C-57 letter of Authorization to sign permit <br />STrc�✓ <br />INVOICE <br />