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Joaquin`County , <br /> FILE TOPY <br /> r z Environmental Health,Dep rtment SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockt n,CA 95202 MITIGATION <br /> �At, '/ (209)468-3449 Fax: (209)468-3433 Web: www.co,san-joaquin.ea.us/ehd UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRC Lill MATE ISSUED ' O <br /> Coun fora P ermit to construct and/or install the work described. This application is made in comp ante with San <br /> Application is hereby made to San Joaquin ty <br /> Joaquin County Development Title,Chapter 9-1195.3 and the Standards of San Joaquin County Environmental Health Department. <br /> i <br /> Assessors <br /> WELL Location P 1 3 W Cross Street v ity Zig / --Parcel# �� Q� q1 <br /> PROPEKY <br /> Owner_ I Address-10,CL 6 1 city Zi G'��/ cP�hone# cam Y <br /> C-57 Contractor ddress q_50 H,",G IL Ci Zip f !%LLO ori hone# <br /> Consultant I Sub Cntr Address3325& it�_Lic#ti� O Phone# <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 8 NEWNZOIL <br /> LL! BORING ��GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> BORING# Q OVER-BORE. DIAMETER <br /> ELL# p PRESSURE GROUT <br /> 0'Other GROUT SPECIFICATIONS. <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIO14S <br /> a MONITORING d HOLLOW STEM DIA.OF BOREHOLEM LTIPt_E CASINGS Q MULTI-LEVEL WELL CASING DIA:II <br /> a EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> ji VAPOR a MUD ROTARY DEPTH OF GROUT SEAL Ga TREMIE TYPE TO BE USED: UGERS p HOSE <br /> d AIR.SPARGE!OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes No (NOTE: MAXIMUM ARE - AL DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS 0� Yl <br /> Q OTHER:_9 OTHER APPROX.BORING DEPTH___p56 p BOLTED TRAFFIC BOX or p TOVE PIPE <br /> CONDUCTOR CASING PROPOS ED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> !VOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRI D FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be clone in accordance with San Joaquin <br /> County O antes, Rules and Regulations, ap all applicable California State Laws. <br /> Signed x itle/Co mpat ty <br /> Print Name O S� Date r O <br /> i <br /> DEPARTMENT USE ONLY <br /> f <br /> SITEMAPIN UNIT IV FILE,ADDRESS: �• "� - �� <br /> WORK PLAN DATED: Ste' O <br /> Application Accepted By Dae Issued I Area <br /> Grout Inspection By Date Final inspection By ate <br /> Destruction Inspection By Date ! <br /> COMMENTS!CONDITIONS: <br /> r <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'U BY DATE PERMIT/SERVICE REQUEST# INVOICE i <br /> 3svl67Zo •2 S <br /> C-57_ WC___ WAIVER, C-57 Letter of Authorization to sign permit Encroachment dot. <br /> $HD 29-02-00 t <br /> 9/30/2002 <br />