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rY)\ <br />WE SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY UNIT IV ENVIRONMENTAL HEALTH DEPARTMENT (F4164)2 1 2002 304 E. Weber, Third Floor, Stockton, CA, 95202 <br />(209) 468-3449 ENVIRONMENT HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DiCTLFIMLSER VICES <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 Joaquin County <br />Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />PROPERTY Owner L'13010 4 IbtUfa Addresan 2fr Zity MAI tea._ ZiA-33(0 Phone# <br />C-57 Contractor I.Josi- faz kg" Addrese -rattee a_ City SAC_ Zip C*749ic#55W4one# <br /> Address 13437 stvz.„44-kzeiv4c# <br />GIS Coordinates: X , Y <br />Vp <br />RK TO BE PERFORMED: <br />EW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # a OVER-BORE <br />ATWELL # a PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS: <br />WELL PERMIT APPLICATIO <br />WELL Location 5 /.158 See- h Eibed Cross Street CiOSC)6490- Zip Iri:749 Parcel# <br />Assessor's <br />Consultant / Sub Contractor <br />'94*16 Zr2(4> <br />Phone# 497 I DzAr, <br />, Township Range Section <br />TYPE OF WELL <br />MONITORING <br />/if/EXTRACTION <br />/VAPOR <br />U AIR SPARGE <br />SOIL BORING <br />U OTHER: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />,2(H—OLLOW STEM DIA. OF BOREHOLE gireAlULTIPLE CASINGS? a YES 0 NO WELL CASING DIA: <br />II AIR HAMMER/DRIVEN CASING THICKNESS / TYPE OF CASING: a STEEL (ePVC a OTHER: <br />U MUD ROTARY DEPTH OF GROUT SEAL /6 Fr:CT — TREMIE TYPE TO BE USED: UGERS 0 HOSE <br />G PUSH POINT/ GROUT SEAL PUMPED: 0 Yes A/No (NOTE:rXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS: POte.74C-vt- <br />I] OTHER APPROX. BORING DEPTH 1715 --rer a BOLTED TRAFFIC BOX or STOVE PIPE <br />*COMMENTS: <br />CONDUCTOR CASING PROPOSED? ( if YES, list specific ions here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br />Rules and Regulations, and all applicable California State Laws. <br />I)dta.c. 6 E- <br />a? <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br /> <br />8116-8 .ee-6-z)-1 <br /> <br />Oet, PeC e257J:/ <br /> <br />Application Accepted By s.--nr\ Date Issued g)-1 Area t ki") <br />- Date 3( ( I 6 2 <br /> <br />Date 12) ( I -2---"Final Inspection By '111\ Grout Inspection By — )11. ' <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />Signed x <br />Print Name <br />tirni& ••• Title/Company <br />Date <br />ACCOUNTING ONLY: AID# FAC# (- 5RPC),S15>qa_13 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / INVOICE <br />l 6`.0/3 4?-1 7s SR# ..2-3 / 7 3 <br />C-57 WC -WAIVER <br /> C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02