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012,0, 13 00 2094683433 rlr Irl <br /> ball Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax (209)468-3433 Web www siyav orglehd UNIT IV <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ApplrCalron Is hereby made to San Joaquin County for a perm to construct and/or install the work descn bed This application rs made in compliance with San <br /> Joaquin County Development TI[le Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department. <br /> OIcs��`�� Assessors <br /> !f <br /> J <br /> oWELL Location CrossStreet S e City Parcew <br /> PROPERTY 0 .V1 <br /> Owner-L2-c kI.Mr r <br /> PGr�,�rAddress 3 EosC%rpm L- Cay SF--11146^ Zip 520SPhone# <br /> qY <br /> C-57 Contracto ­11 - � �4wL Gty c/ ZZZp Lrc# �`eYS�14S-Phoneg <br /> S313-S Sao <br /> Consuttant! <br /> Sub CrsV�,..bri� Lrc# Phone# o -33-2369 <br /> GIS Coordinates X Y Township Range Secbon <br /> WORK TO BE PERFORMED <br /> ,VNEW WELL I BORING (CPT, GEOPROBE HYDROPUNCH HAND-AUGER OTHE=R`) p DESTRUCTION (choose type below) <br /> []SOIL BORING (I OVER-BORE DIAMETER <br /> a WELL#_ t L✓ -7 ren U-2 _ Q PRESSURE GROUT <br /> 11*Other GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WE LL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS it <br /> M,WONITORING AHOLLOW STEM DIA OF BOREHOLE 0 MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA Z <br /> Q EXTRACTION Q AIR HAMMEWDRIVEN CASING THICKNESS r TYPE OF CASING p STEEL A PVC U OTHER <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 3 TREMIE TYPE TO BE USED AUGERS p ROSE <br /> AIR SPARGE/OZONE 13 PUSH POINT(GP or CPT)GROUT SEAL PUMPED )(Yes Q No (NOTE MAXIM/UM FREE-FALL DEPTH IS 30') <br /> OIL 60RING l] HAND AUGER GROUT SPECIFICATIONS _ po_r_f�al17 Ce•-.c ar _ <br /> DTHER OTHER APPROX BORING DEPTH Sd r BOLTED TRAFFIC BOX or j]STOVE PIPE T <br /> CONDUCTOR CASING PROPOSED k) (T YES, Inst specrficatlons in comment section) <br /> COMMSNTS <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 O Inances, R s-an Regulations,and all applicable California State Laws <br /> Signed x r Title/Company ),)2C9C1�11��C-� <br /> Print Name Date -L11_�1_C7q <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS. <br /> WORK PLAN DATED. <br /> ApplrcaUon Accepted By `- j r Date Issued <br /> C [ j ��"T Area <br /> Grout Inspection By J Date anal Inspection By Date <br /> Destruction InspecUon By Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AIO# t=AC# <br /> Pf~CODES FEE INFO AMOUNT REMITTED CHECK V RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE j <br /> C-b7 WC -WAIVER C-57 Letter of Author a to sign permit Encroachment doc r <br /> ERD 29-02-01 <br /> 9/302003 <br />