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no55d<-(F Y"r,vV.�r <br /> WA PERMIT APPLICATION FOR SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) UNIT IV <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209)468-3449 <br /> ' NON REFUNOABLF PERMR EXPIRES 1 YEAR FROM GATE ISSUED <br /> Application is hereby maSan Joaquin CaunH fvr a parmil to concituct and/or Install the Work descnbad. This appgcadon LL made In wmpFance with San <br /> de LLo <br /> Jaaq(ln County Development Tile.C'hagwr 9-1115.3 and me Slandards�offfSSan Joaquin County Environmental Health OepeM,ent <br /> Aaseswrs <br /> t WELL Lowtlen A)4Ee O^'K C, yGota 6.4tC%dU�°'' IY Z'P PercaN <br /> ros [upo (�[ ,--D <br /> - PROPERT//; �[ / .rr _ �} _7�p }70 Phans 8�J Zr <br /> Owner rix BPdtlress Q°'f OIIY <br /> ' C-57 Conireelor '&�I Address Sf' CiIY LP ��Lr-"�� hon b�� �/� <br /> Censullanit Sub Cno L '"6" Add <br /> -6'Lf"6J"t yd-17-� CitY7 Licit PhoneZsy�-/�y� <br /> Toonshlp Ptwga Section <br /> GIS Coordlnalas:% �Y <br /> 1 WORK TO BE PERFORMED: aymn ESTRUCTION (choose t a law) <br /> 0 NEW WELL I BORING (CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') .J_t`1=R-BORE. D,METER�r <br /> QSOIL 9ORIN�R�,� a PRESSURE GROUT <br /> ELttl — GROUTSPECIFIC9TIONS P.aal- rel+r•'l-f <br /> ' Omer {.ewt.fl, P to rcu, <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION <br /> ( PE FCU <br /> 9YMONRO INO *OLLOWSTEM O,.OF BO�rQMLTIPLECASINGS GMULTI-LEVEL WELL CASING IIA:Ij/yr <br /> ' B EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS'C4 1*0 TYPE OF CASING: ()STEEL t4VC p OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TFIFMIE TYPE TO BE USED: $,AUGERS 0 HOSE <br /> ' 0 AIR SPARGEI OZONE Q PUSH POINT(CP or CPT)GROUT SEAL PUMPED: )(Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 70') <br /> D SOIL BORING 0 HAND AUGER GRCUT SPECIFICATIONS <br /> u OTHER: n OTHER APPROX-BORING DEPTH 621 0 BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES.list spaciricalons m wrnmenl sectlon) <br /> ' COMMENTS: S S � K' 4 <br /> NOTE: OFFSITE BORT G5 REQUIRE ACCESS AGREEMENT ORE CROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that[have prepared this application and that the work will be done in aceordande with San Joaquin <br /> County Ordinances,Rules and Regulations,and all applicable California State Laws. <br /> ,Q. <br /> Signed a ' I��7 <br /> Oate <br /> PrintNamo DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DAT2D: <br /> Date Issued Ales <br /> — <br /> CONDUCTOR <br /> Accepted By Date <br /> Grout Inspection By Dale Final Inspection By <br /> ' Desrrueeon Inspection BY Data <br /> COMMENTS t CONDITIONS: <br /> ACCOUNTING' ONLY:I AID# FAC#PE[ODES FEE INFO AMOUNT REMITTED CHECK# REDID BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br /> ' C.57_ WL_-WAIVER_, C-57 Letter pf Authorization to sign permit_Encroachment doc� <br /> 9/30!02 <br />