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BATE <br />/7-y C:30— ;- 7 y ci <br />WC -WAIVER C-57 Letter of Authorization to sign permit_ <br />ACCOUNTING ONLY: I AlOd <br />I' F CODES FEE INFD AMOUNT REMITTED [CROCKS REVD EIV <br />FACd <br />Olt/ <br />Final inspecGon By _ [Ude <br />AM" <br />COMMENTS! coNDITIONS: <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED; <br />AppIlenCen Acc.eptad By ijk/IA-0-f-A.. Date Issued V <br />Grout Inspection By <br />Onstrudion In5poction BY_ <br />Dour <br />Date <br />PERMIT <br />012-6 <br />oochrnerst doc 9/30/02 <br />E REQUEST NVOIC.E <br />nnfizeLn ATR YVA LT:AT 31-I,T. tiO/AR/TO <br />qUOUT , <br />GROUT SPECIFICATIONS, T ke. yr cl-e <br />39p Wane woociwarci <br />1-707-374-5677 <br />P - 2 <br />06/13/ 2003 913:(32 2094683433 <br /> FIFTH FLOOR <br /> <br />PAGE 04 <br />JAN 0 8 2004 <br />ENVIRONMENT HEAD IN <br />304 E. Weber, Third Floor, Stockton, CA_, 95202 <br />PERMIT/SERVICES <br />(209) 465-3449 <br />nom.stErialoatz PERMIT EXPJ/RFJ5 1 YEAR FROM DATE 1SSuEp <br />tcppli 03,4CM IS <br />hereby made to San Joaquin County tor a permit la construct end/or instant/le work described. Th15 application la made in compliance wilti San <br />toaquIn County <br />Oc-relopmenl Title, Chapter 8.111S-3 and the Standards of San Joaquin County Emrtronmerilal Helddl DePardn <br />erst <br />NELL Location .--'''' if ---5-- -FM LI 't t u 01' . cross suoet (:- t crv e r Rdi • coy I rm.. Lie zip <br />'Or:1k Nz dre,,,. v 0 R --.3 c 71 1'45—Ike "?- /06-4 haw .c_13- ---3 .4-4, -t-f3 ad city r'`'n---, -- Pp9445 30Phonett 9 25 '4_99 - 119 1 <br />2ROPENTY owner c...., 7-ti_ ..'._3, .".....C.LellAddr... tcA - ac,-3... (5 ,4 9 <br />c--f. <br />Range Scotian <br />GIS Coordinalms: X <br />WORK, TO DE EERPORMED: <br />0.r4E-w WELL I BORING (CPT. GEOPROBE. HYDROPUNCH,. HANV-ALIGER, orHER1 <br />13 5011 BORING P <br />4&EL1- #J1-.1 <br />Othip, <br />COM MENTS: <br />-0 c if-ruc-t-j4 — <br />-iterrAL-4=A-Tiati TYPE TiOtSghtErIE S <br />AttIOLLOW STEM DIA. OF BOREHOLE_ , D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIAL <br />U AIR HAmMER!DR1VEN CASING THICKNESS__ "TYPE OF CASING: 11 sTEEL g PVC 1] CITHER: . <br />ii MUD ROTARY DEPTH OF GROUT SEAL <br />SPARGE/ OZONE n PUSH POINT (GP or CPT) GROUT SEAL P C <br />p SOIL actRG.....i,..i.r.„0 HAND AUGER ' GROUT orecIFicAnoNs irk-e_iiki— Ce .-. oi....1-- <br />34 0 THER: -... r ... Ltd.- 0 OTHER . APPROX. BORING DEPTH II BOLTED TRAFFic Box er a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES. fist apecificos1Jons in comment 5ectlon) <br />commENTS: <br />NOTE: OFFSITE <br />BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERNIITS. <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 Regulatio ail applicable California State Laws. <br />Signod <br />Toietcompany (4.)c/beA ev- <br />vrin 1 N BRIO Zjer9 P:^16 <br />Date 6 - <br />DEPARTMENT USE ONLY <br />PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (END) <br />SITE <br />MITIGATION <br />UNIT IV <br />C-67 cractor <br />Consultant / Sob Gnu- Cdy <br />.0 <br />A4kitire4‘,153?-1-1 C ty Llod`R. -4-1 Phone,. 7 /‘ ?-4 T)ror_c_LT ite rern_ <br />Township <br />TYP OP WELL <br />MONITORING <br />P_xTRAVTION <br />FT VAPOR UMPED: Xf I) No (NOTE: MAXIMUM FREE-FALL DEPTH S 30') 1-1C)* <br />IRENE TYPE TO BE USED: 11 AUGERS TOSE