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COP"an Joaquin County F11 F Y <br /> Environmental Health Department SITE <br /> j 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (20 9) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ')F, UNIT IV <br /> rF0 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUL 9 p <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. ,ibis applica5tin compli ce with n <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environment artrnent. <br /> _ 1 PER <br /> WELL Location Q - 7Jr CCeti r1Ub elyd Cross Street � q_11 Rj City STDGk-I Zip, <br /> PROPE TY , 123 <br /> O er E 11M E IW Y SBS CAddress ( dj$D POST ovk IblV��110 City b'U rVA -_ Zip77oS6 Phone# <br /> c o Te AST ny4, y [�� <br /> C-57 Contractor �i DN% Address `/5o !lvurG Ave CityGY1i Ytt2 Zip YySS�tic# $S Phone#9/t ,/ a�3 - SSDD <br /> Consultant l srltT-MCawtbl^ la Address027o Ft°. WOS 9, City ��11 Lie# Phone# 707- 9 �f- 'Vi3 <br /> GIS Coordinates: X., Y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑ NEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') XDESTRUCTION (choose type below) <br /> 0 SOIL BORING # `OVER-BORE. DIAMETER2: 10 � <br /> p WELL # p PRESSURE GROUT <br /> 0 *Other GROUT SPECIFICATIONS <br /> itOMMENTS: Iii END ItS t Sorry CNM ffQ�rlo �tfHa ) Q)roUT�ber��at � <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,MONITORING OLLOW STEM DIA. OF BOREHOLE i a MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sala 40 TYPE OF CASING: D STEEL XPVC 0 OTHER: <br /> p VAPOR p <br /> MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [] AUGERS p HOSE <br /> p AIR SPARGE/ OZONE p PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes 9 No (NOTE : MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING p <br /> HAND AUGER GROUT SPECIFICATIONS <br /> 11 OTHER: tI OTHER APPROX, BORING DEPTH o2 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> - CONDUCTOR CASING PROPOSED — (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 Ordina Fc gulations, and all applicable California State Laws- <br /> Sigoad .. l�LelCompany Print Name Date <br /> DEPARTMENT USE ONLY � <br /> SITE MAP IN UNIT IV FILE, ADDRESS : 25�s & at4ops <br /> WORK PLAN DATED ' 0 4 11111 <br /> 4 <br /> Application Accepted By Date Issued 1 , �� •- a� <br /> Grout Inspection By Date Final Inspection By !!► 10;` 1 � at <br /> �. <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # 'D BY DATE PERMrr I SERVICE REQUEST # INVOICE <br /> 35o W bo. ' <br /> 19 t 5 sR# <br /> REC31191 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign pernlih# <br /> Encroachment doc <br /> EHD 29-02-001 <br /> 9/30/2003 <br />