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05/18/2004 14: 12 2094683433 FIFTH FLOOR PAGE 02 <br /> o gl•IN 4an Joaquin Aunty • 4 <br /> �'iL�C�C� V=E <br /> : Environmental Health Department MI TION <br /> 304 East Weber Avenue, 3rd Floor,Stockton,CA 95202 <br /> r (209)468-3449 Fax: (209)465-3433 Web:wwWco.sanjoaquin.ca.us/eMAY 17 20"NIT IV <br /> ` NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONME HEALTH <br /> PEWVSERV��?�-e <br /> APplicatlon is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This application M me1'ffi1rt'>"mpliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> r Assessors <br /> ;if ['�/7_ I __�7,,� ,, <br /> Zip <br /> i �3 Parcel# <br /> WELLLocatlon n( 5J T �) _Gross <br /> Sheet- —70 COY7-I - P <br /> PROPERTY G Address-. .J, �PLI City-�Z�'P� Phone# <br /> Owner 16U 5At.2of Cl <br /> /ri I p rc �_ Address •0. City 1 'L Zip l,?(FJe�,A7,Lic# honeN� JYOr' r�/ <br /> C57 Conlrecwr �t, J•,1 IVF"' Phone# �%D��77 <br /> ' i AW � Sit r Ad '296 G IN e _CIitYS ICU Lic# <br /> Consultan!!S <br /> GIS Coordinates:X <br /> Y ,Township Range Section <br /> WORK TO BE PERFORMED: pES7RUCTION (choose type below) <br /> p NEW WELL I BOZG* <br /> (C ,GEOPROB ROPU AND AUGER,OTHER`) 0a OVER-BORE. DIAMETER ` <br /> 0 SOIL BORIa PRESSURE GROUTJC6�U <br /> 0 WELL# GROUTSPECIFICATIONS4-'V-- Cfnn .. <br /> e 'Other <br /> COMMENTS SCC�� OL dA �� <br /> TYp DF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> SLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br /> a MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE__ a <br /> MULTIP0 EXTRACTION Il AIR HAMMER/DP.IVEN CASING THICKNESS TYPE OF CASING: G STEEL [I PVC a OTHER: <br /> ()VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL <br /> TREMIE TYPEYO BE USED: I1 AUGERS O HOSE <br /> AIR SPARGEI oZONEIPUSH POINT(GP or CPT)GROUT 5EAL PUMPED: 0 Yea n No (NOTE' MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 1 HAND AUGER GROUT SPECIFICATIONS o j]BOLTED TRAFFIC BOX or STOVE PIPE <br /> OTHER: (1 OTHER APPROX.BORING DEPTH 1 ) <br /> CONDUCTOR CASING PROPOSED— (d YES,list specifications in comment section) <br /> COMMENTS: <br /> I NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> '} I hereby certi t at I have pr pared this application and that the work will be done in accordance with San Joaquin ` <br /> County Ord' a ccs ules d Regulations,and all applicable Californ tate Laws. �� <br /> '� Slgnedx Title/Company <br /> ��, 4� t I � r <br /> Dale ! <br /> Print Name <br /> ') DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORKPLAN DATED' 6y 6 �Sh 99-7 <br /> ' /)� �� p _InspecDate Issued s��e�� <br /> ApplieaUon Accepted Byy A Oate Final tion Date <br /> Grout Inspection By <br /> 11 Destruction Inspection BY Date <br /> J4 COMMENTS I CONDITIONS: <br /> _ ACCOUNTING ONLY: AIO# FAC# <br /> I <br /> '1 PE CODES FEE INFO AMOUNT REMITTED CHECK# RE ID BY RATE PERMIT 7 SERVICE REQUEST# INVOIc <br /> a.�t.ol $moi- <br /> C-57— WC--WAIVER— C-57 Letter of Authorization to Sign permit_ Encroachment riot_ <br /> I <br /> e14D zaoz-oo I <br /> 9/3012002 <br /> 1} 05/16/2004 TUE 15:07 [TX/RX NO 54071 [f)J002 <br />