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JUN -22-2004 15:11 CAMBRIA <br />0411 duayuilit %-Vufity <br />Aim& Environmental Health Department <br />1W304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />P.02/05 <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 Sa <br />Joaquin County Development Title, Chapter 9-1115,3 and the Standards of San Joaquin County Environmental Health Department. <br />t� <br />Assessors <br />WELL Location `191Q ib7',nlc>r ur�-�r1,r, t�t� t�c.�,Cross Street j4An%Aye r Lrw City �yFtS[. K:it r.. Zip Parcel# --: �) �j ci o - <br />PROPERTY <br />Owner C11 flit Pgt&4 ICt'S-IAS Address; r,44 :. 1di:ipt� a. City td�Ia�r� Zips Phone ri�cti�f���j � 13;. <br />C-57 Contractor --,.1 Ot"IM Address``r150 &J4,0— I&A City;�i�,x{►l�GZZip AF5 3Lf 51 SPhone#`�2� 313-599- <br />Consultant/ Sub Cntrt& %N IC( CitySt,,,cMrh Lic# phone#-?QLq33-2-30 <br />GIS Coordinat®s' X Y, Township _ Range Section <br />WORK TO BE PERFORMED: <br />p NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 SOIL BORING # <br />n WELL # <br />n "Other <br />COMM <br />rl 1 <br />n DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER,. <br />jWRESSURE GROUT <br />GROUT SPECIFICATIONS LAW -1 4iAvtA ulL)- <br />_LYPE_OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING n HOLLOW STEM DIA. OF BOREHOLE___ p MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA: <br />p EXTRACTION <br />n AIR HAMMER/DRIVEN <br />CASING THICKNESS <br />TYPE OF CASING: n STEEL n PVC p OTHER: <br />n VAPOR <br />n MUD ROTARY <br />DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: [)AUGERS 0 HOSE <br />n AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: n Yes <br />0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30' <br />0 SOIL BORING <br />n HAND AUGER <br />GROUT SPECIFICATIONS <br />PERMIT / S>=RVICE REQUEST # <br />n OTHER:. <br />fl OTHER <br />APPROX. BORING DEPTH <br />n BOLTED TRAFFIC BOX or n STOVE PIPE <br />T7 is <br />/1 <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment sector <br />COMMENTS:_._..._ <br />_. <br />oiJ 1 il4 lA_� <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 O es, R I s and Regulations, and all applicable California State Laws. y <br />Signed x Title/Company i6c�LL1�tG;�tVJ i'���I li�li'Yt l �i �a/NG%G ;- <br />Print <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE_ ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By L'1 �11YIZ'C'-Z^ Date Issued <br />Grout inspection By Date_ _ . Final Inspection By <br />Destruction Inspection By Date J ' <br />COMMENTS IC <br />Is <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />3, <br />(� �?L <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / S>=RVICE REQUEST # <br />INVQl6 <br />T7 is <br />SR# <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit__ Encroachment doc� <br />EIiD 29.02-001 <br />9/30/2003 <br />N: <br />