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,17/2004 13 00 2094683433 FIFTH FLOOR PAGE 03 <br /> C VMli VVM\�MAI� �/vwurJ <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> y (209)468-3449 Fax (209)468-3433 Web www sigov org/ehd UNIT IV <br /> D <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appllcat+on,s hereby made to San Joaquin County for a permit to construct andror install the work described This applleaton is madam compliance with San <br /> Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> �// 1 Assessors <br /> WELL Location 1 313 1&,- (. �f e�� J Cross Street r L L✓{Pty <br /> PROPERTYAl r A t.rn411ak+ <br /> Owner �S5{'.� 1 arn+� Address Zll , Ccs � Blued Cory L-olr Zip 952 (0 Phone# 209 -x d?3-0/99 <br /> GS 7 <br /> C-57 ConUactor,�rh ddress -n 9,5C;Ar,,-r •e Cp 9YZ3 Lrc# 51 Phone# <br /> Consultant/Suh Cntr Cz,4rrg lei Address_2 70 fc­Q^>5City Gina. -,_Lac# Phone#70?- <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> gNEW WELL 1 BORING (CPT GEOPROBE,MYDROPUNCH,MAN D-AUGER OTHER*) a DESTRUCTION (choose type below) <br /> 0 SOIL BORING# DOVER-BORE DIAMETER <br /> ,HWELL# M fJr 0 PRESSURE GROUT <br /> 1]'Other GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS rr <br /> Y91MOMTORING HOLLOW STEM DIA OF BOREHOLE 2 " 0 MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA, Z <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ;F4&!(O TYPE=OF CASING a STEEL A PVC 1]OTHER <br /> []VAPOR 1]MUD POTARY DEPTH OF GROUT SEAL 3I TPEMIE TYPE TO BE USED AAUGERS 0 HOSE <br /> IR SPARGEI OZONE 1]PUSH POINT(GP or CPT)GROUT SEAL PUMPED XYpes /No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> LBO <br /> []HAND AUGER GROUT SPECIFICATIONS <br /> 0 THER! rI OTHER APPROX BORING DEPTH 5t9 r SOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /Cr0 (if YES,Inst specifications.n comment section) <br /> COMMENTS <br /> NOTE' OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <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 Or Inances, Rules and Regulations, and all applicable California Spate Laws <br /> Signed x - Title/Company -.111 <br /> Pnnt Name <Q,A'-t e�IST`F� Date S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS- <br /> WORK PLAN DATED' <br /> Appllcatior Accepted By Dale Issued <br /> ry L4 Area <br /> Grout Inspection By Date Final Inspection By, male <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AID# FAC* <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST 0 INVOICE <br /> r ` 2ooS� U I SR# OCA <br /> C-57 WC -WAIVER C-57 Letter of Author otio t sign permit Encroachment doe <br /> EHD 29-02-01 <br /> 9/30Izo03 <br />