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0 <br /> %.-,)an 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.co.san-joaquin.ca.us/ehd UNIT IV <br /> Q<<F 0RN� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-111155--3 and the Standards�of1San Joaquin County Environmental Health Department. <br /> /" I WL)r l L�+� ✓ 1 LINUUt-.1`� city Zip9T240 Parcel#Assessors <br /> WELL Location�, Cross Street Ci [C(,I(.[C1.1 Zi <br /> PROPERTY/!�l* `/ ��,Q�p.� ' 1 �I / Q G/ <br /> Owner 00 C 7 1 I'�rWjf iAddress t�f 4). n-Ay! city'` ;x/ Zip 75 <br /> �l S C�O� <br /> jJ <br /> C-57 Contractor Hra-wc_L. )"j1M4(,Address/b6/f�AL/IZZC uAU Citya L)VV& ZipCS 'A Lic4-aO17 PhoneA1 3/- rC <br /> Consultant/Sub Cntr Alx+ajwa 6-4A1J1LiNM�~Address TY7 S'd>� City- r- 14 Lic#LPhone# AC 7-1606 <br /> GIS Coordinates:X —'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> '-ANEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER.OTHER') p DESTRUCTION (choose type below) <br /> j� 0 SOIL BORING# a OVER-BORE. DIAMETER <br /> WELL# N w J I AL1 kl&L-'- p PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:z <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS&Cq qc-1 TYPE OF CASING: a STEEL A PVC Q OTHER. <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL a I TREMIE TYPE TO BE USED: 4 AUGERS a HOSE <br /> []AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Ye� )(No (NOTE: MAXIM4/M FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS rOQTL `� CV/Pf- 4/ir <br /> OTHER: Q OTHER APPROX.BORING DEPTH 3U' KBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /'\(U (if YES,list specifications in 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 ces, les and egulations, and all applicable California State Laws. <br /> �. )_ - <br /> Signed x ``.. —Title/Company r:L�.-lS f�l[!k!� .�r v� ' rJar4t <br /> Print Name �1+/ .L1�Tc � Date 04, 64-0 T <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By_ Date Issued) �Oy Area <br /> Grout Inspection By Date Final Inspection By to JL'4 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3601 y`i . 00A 2 0 o�} sR# 3 O I <br /> C-57_ WC=WAIVER_ C-57 Letter of Auth Izat n t sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/30/2002 <br />