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d <br /> Pn� ' H San Joaquin County <br /> 2� y Environmental Health Department SITE <br /> � 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> 1 4oa <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.co.san- uin.ca.us/ehd UNIT IV <br /> . <br /> M <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 /> WELL Location 16 I ( s®• rGP+S?O , p, Cross Street La Ci � " n Assessors <br /> y tyr 55 e TOJt Zip 4520h Parcel# <br /> PROPE }��v ✓� / <br /> Owner 104 5 Address R7-fq�,, ,ham-ycily �_40 k Aw Zip 95nPhone# 109- Qom/ - 7283 <br /> C-57 Contractor r ; AddressO/50 htw✓e City/J�- 5i/OsPhone# 9ZS % <br /> 313 - W@@ <br /> Consultant / Sub Cntr (_'�QtfN/d ��o Address 22% jajA:s�r Cily P&G Llc# Phone# J5/o • 307] . 99'f3 <br /> GIS Coordinates: X , Y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> JEW WELL / BORING (CPT, GEOPRQ BE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> J SOIL BORING # i3 ' 2• / •-'7X92—X92— 0 OVER-BORE. DIAMETER <br /> WELL # T - / =C=ue _ /2_ 0 PRESSURE GROUT <br /> `Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING I HOLLOW STEM DIA. OF BOREHOLE_sFIV� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2�✓C <br /> 0 EXTRACTION fl AIR HAMMER DRIVEN CASING THICKNESS TYPE OF CASING 0 STEEL ? PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Y1 +4: TREMIE TYPE TO BE USED: GAUGERS III HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: j Yes No (NOTE : MAI UM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS r9j � a <br /> OTHER: 0 OTHER APPROX, BORING DEPTH 961 1 B TED TRAFFIC BOX or 0 STOVE PIPE <br /> f Qa' CONDUCTOR CASING PROPOSED $ (if YES, list specifications in comment section) <br /> COMMENTS: PGVf C .una/n "it C&i 2 5 o &nd2i�j i to ju 0 ( 4 00 <br /> 02E: OFESiTEBORINGS-REQUIRE-AOiC€SS-AGREE-UEt4-T-Oki-€NC ROAOI#MENT-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 O ances, R fi and Regulations, and all applicable California State Laws. / p , <br /> Signedx Title/Company � �Z-- /Cl4R�V��I.O-c.( �Tt611�7 <br /> Print am pate •5I2$ 10 � <br /> DEPARTMENT USE ONLY Tr <br /> SITE MAP IN UNIT IV FILE, ADDRESS : IFS / A `o. <br /> WORK PLAN DATED : Mod Z 1 2_00 J <br /> Application Accepted By���� CA= Date Issued 3= 11410y Area 14 Z1, ;? <br /> _ <br /> Grout Inspection By Date Final Inspection By Date - <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: C ) C K. <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUUEST # INVOICE <br /> . 350 ( T7oOO $�O`l lE by SR <br /> # 3 � � Z I <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/30/2002 - <br />