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Title/Company <br />Application Accepted By <br />Grout Inspection By Date It Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />Date Issued I t 1 0 Area Final Inspection By LAumaciad WI Date___LLI Date <br />AMOUNT REMITTED <br />INVOICE <br />PE CODES <br />3 re, <br />35-0 3 <br />FEE INFO CHECK # REC'D BY <br />C-57 WC -WAIVER <br />EHD 29-02-001 <br />6/22/04 <br />C-57 Letter of Author zation to sign permit 7 Encroachment <br />OC <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 WAID: www.sjgov.org/ehd m1111115 . • mit Applic a tion <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDAICA ''''13:4)1TEAY+R FROM DATE ISSUED <br />Application is hereby made to San Joaquin County fctrl wrrlitRot6j3tAbit iritiliKtall the work described. This application is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.8 ad the Standards of San Joaquin County Environmental Health Department. <br />WELL Location ___/.22) \ Cross Street c--focie.--1-eliN Zip 95z1Parcel# <br />Assessors <br />Consultant / Sub Cntr <br />GIS Coordinates: X <br />Range <br />Section <br />GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />COMMENTS: <br />0 VAPOR °MUD ROTARY <br />a EXTRACTION fl AIR HAMMER/DRIVEN <br />a MONITORING a HOLLOW STEM <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 AIR SPARGE/ OZONE }KISH POINT (GP or <br />O SOIL BORING a HAND AUGER a OTHER: a OTHER <br />COMMENTS: <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, R les and Regulations, and all applicable California State Laws. <br />Signed x <br />WORK TO BE PERFORMED: <br />EW BoRING <br />aSOIL BORING # a WELL # Q *Other <br />PROPERTY <br />C-57 Contractor re <br />Owner "Er <br />sjjZILPhone# <br />. ___Address <br />City ZipLic# "honeit c,_ Address City Lic#.6._2_17 Phone# <br />, Y , Township <br />O DESTRUCTION (choose type below) D OVER-BORE. DIAMETER <br />PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />(if YES, list specifications in comment section) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT R <br />O ENCROACHMENT PERMITS. 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2" D MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: CASING THICKNESS L__ TYPE OF CASING: a STEEL 0 PVC a OTHER: DEPTH OF GROUT SEAL_Scdi_in TREMIE TYPE TO BE USED: trATJGERS a HOSE GROUT SEAL PUMPED: a Yes a-fTo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') GROUT SPECIFICATIONS 1 I <br />APPROX. BORING DEPTH__12 BOLTED TRAFFIC BOX or STOVE PIPE CONDUCTOR CASING PROPOSED <br />Print <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 44 <br />• WORK PLAN DATED: <br />0 e <br />15- 0