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a <br /> .OUIN "an Joaquin County y <br /> Q• � r Environmental Health Department <br /> SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 °hti MITIGATION," <br /> l V. (209)468-3449 Fax:(209)468-3433 Web:www.co.san-joaquin­ca.us/ehd UNIT IV <br /> •P <br /> t 0 <br /> �4C1FORT� - <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to Sart 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 /> Cn .eL 17 nr� „ v�ffb� Assessors <br /> WELL Location?7-/Y� NU/rl rY Cross Street City-39 "'�ZiP Parcel# <br /> PROPRk <br /> Ower f[ Address 3 ,WV!��6 City AGLD Zip9r3Yo Phone# 3o3'y7L� <br /> _ bl Bp Vo &t” °v i # g�/( $�" <br /> 1C1 'Tl � lressbN11( <br /> C•57 Contractor � u3J�3 <br /> Consultant/Sub Cntr }J_ .�7r - Adtlressp37 S/ N r'G"ry CityLid.((/ori LZ�Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: - <br /> KNEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> SOIL BORING#. ji;- O OVER-BORE. DIAMETER <br /> Ya WELL# Yt�q�iwSiy/ /L �O1�r7Y.D QS wHK:.$r 0PRESSURE GROUT - <br /> a*Other / Q GROUT S�P�ECTIC)QTIONS <br /> COMMENTS: /Gf14Nl /7/YtI�Lk�Tl� ! ?iI 13DA./A�(y+S Ai /�(,(/S ��Sby VIVN — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'Q DNITORING �riOLLOW STEM DIA.OF BOREHOLE S_aS'a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: a STEEL a PVC- a OTHER: <br /> p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL &S"�TREMIE TYPE TO BE USED: a AUGERS p HOSE <br /> p AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes gNo (NOTE:MAXIMUMI'FREE-FALL DEPTH is 30') <br /> ,SOIL BORING a HAND AUGER GROUT SPECIFICATIONS RPx7LAr,4 Le»+&' ` l' <br /> ` a OTHER: p OTHER APPROX.BORING DEPTH ys R BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> \ CONDUCTOR CASING PROPOSED WO (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. :l <br /> v r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordir�aR es, R sand Re u 4otasr-and all applicable California�S/tT��)te Laws../'' <br /> Signed x Title/Company V r !Nr <br /> Print Name b Date <br /> �? Z/ <br /> I DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: A I <br /> //J/QPI <br /> Application Accepted By Dat C.- `'"v �a <br /> Grout Inspection By a) Date mal Inspection By to <br /> Destruction Inspection By 1 Date <br /> COMMENTS/CONDITIONS: 'f (�h r <br /> ACCOUNTING 01, AID#S � FAC# O C <br /> } PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'O BY DATE PERMIT/SERVICE REQUEST# INVOIC <br /> 2 j J5�� Z SR# <br /> ZO3'tl <br /> C-57_ WC_WAIVER, .0-57 Letter of Auth i n t sign permit_Encroachment doc_ <br /> EHD 29-02-001 m `-'�,`j �"'� a(SL Cr <br /> 9/30/2002 {),/- 6 7J r i }�� <br />