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a � <br /> oA, U.I San Joaquin County <br /> � <br /> � Environmental HatDartm <br /> SITE <br /> 'e ent JUN 0 12004 <br /> 304 East Weber Avenue, 3rd door, Stockton, CA 95202 MITIGATION i <br /> 1-4 (209)468-3444 Fax: (209)468-3433 Web: www.co.san joaquig.�� ENT HEALT NIT IV <br /> ,SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED� <br /> I , <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. ',This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> d� <br /> ' Assessors <br /> WELL Location AiArk-4 S4-, ross Street Cl SityjVL ZipY2_0Parcel#—/ c� <br /> Ow� RTY <br /> erE�C JOh Address r (0 0OL-City_S�Oa4jy zip Phone a0�Fy6F9"3��a <br /> C-57 Contractor " D,31'-0 Address 0 0, 00x .33 6 City Zipr9 s'% is#7/ap Phane#�07-35��-�/3GD <br /> !Z u ' , <br /> ConsultantlSubCntr .1�1 PvsGQ"4e1 AddressJl3Sl�M�%FrP/GfL City L.or�aLu. Lc# Phone# gl(o-,PS 3'�0- <br /> I. , <br /> GIS Coordinates:X Y Township 'Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL t BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT r <br /> 0`Other i+ GROUT SPECIFICATIONS <br /> COMMENTS: �I _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE C11 ASINGSi 0 MULTI-LEVEL WELL CASING DIA:----- <br /> a <br /> IA:-_--_0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL f REMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> XAIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ,: I (if YES,list specifications in comment section) <br /> COMMENTS: 1 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR tNCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOWINSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done.iin accordance with San Joaquin <br /> COLnty Ordinances, <br /> Rulles amend Regu/lfations, pplicable California St ate Laws. <br /> Signed x !l!I G�lr,�:( Title/Company <br /> Print Name �l Date C <br /> DEPARTMENT USE ONLY' <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_7 IJi w � e., t��__1 <br /> ILI <br /> WORK PLAN DATED: q I �� <br /> Application Accepted By I� Date Issued 13 Z Area <br /> B" <br /> Grout Inspection By U�2,dAA ..� Date Z O Final Inspection By Date $ <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: { <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR <br /> # ` <br /> C-57— WC -WAIVER— C-57 Letter of Authorization to sign perm' it (Encroachment doc <br /> ii <br /> EHD 29-02-001 <br /> 9/30/2002 <br />