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r <br /> Q'Wy -Sian Joaquin County' <br /> Environmental Health.Department SITE <br /> �, MITIGATION_ <br /> 304 East Weber Avenue, 3rd Floor, Stocktori,CA 95202 l <br /> �. :. UNIT IV <br /> (209)468-3449 Fax: (209)468-3433 Web: www.co.san joaguin.ca.us/ehd <br /> .. sp. i k.:. -I <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> _ Assessors p <br /> r W S! Ci p - G '' Parcel#rr-, 7��7 Z Z <br /> S; ' Cross Street --city ~L� Zi <br /> WELL Location ����� (� <br /> PROPER �� ML f �ity��Zip-17�-Phone# <br /> Owner �% ,. 1 k Address <br /> C-57 Contractari'�1 Cld t L 4ddress ? 3 S• 7 City Zi.p �Z6 Lio*.�72(a7 Phone# I G� �FG3 <br /> 37M*-) Ci Li �,f-4ZZ7...Phone# G-7-JaE <br /> Consultant/Sub Cntr Q DI/,AA�L�iD Address <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL I BORING (CPT,GEOPROBE,HY❑ROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION' (choose type below) <br /> p 0 OVER-BORE. DIAMETER <br /> SOIL BORING# _ <br /> 0 <br /> WELL# iU t a- vl W- PRESSURE GROUT A` <br /> p`Other GROUT SPECIFICATIONS <br /> COMMENTS: F <br /> j <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r i <br /> t` MONITORING HOLLOW STEM DIA.OF BOREHOLE,: 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CA51NG DIA: <br /> d EXTRACTION a AIR HAMMER/DRIVEN ' CASING THICKNESS. `fc TYPE OF CASING: 0 STEEL-APVC BOTHER: <br /> p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL ^-2b t TREMIE TYPE TO BE USED: AUGERS a HOSE <br /> p AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: >R•Yes a No (NOTE: MAXIM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING D HAND AUGER ;# GROUT SPECIFICATIONS <br /> 0 OTHER:_n OTHER APPROX.BORING DEPTH i _0 BOLTEb TRAFFIC BOX ar U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifcations'in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. j. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> Count)l Ordi nces,7-­Ru4es_a1 Regulations, and all applicable Cal iforniiaajState Laws.. <br /> Signed x Title/Company f p'fJ-k C11+Lffjr <br /> Print Name L Date <br /> DEPARTMENT USE ONLY <br /> r SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> r y Date Issued '7/2 U r Area <br /> Application Accepted By <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS:Aft✓ <br /> ACCOUNTING ONLY: AID# I" FAGS k. <br /> PE CODES FEE INFO AMOUNT REMITTED ;I, CHECK# REC'D BY DATE PERMIT I SERVICE'REQUEST# r INVOICE <br /> r <br /> �p'7�SZ �� 7 SR# <br /> C-57— WC=WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> LHD 29-02-001 <br /> 9130!2002 <br />