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Joaquin County <br /> 2 % Environmental Health Department SITE <br /> a <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> CQ�1FO�a\� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JoaquinlCounty De a opmenot Joaquin <br /> C9-1115.3rand the permit <br /> Standa ds of Sanand/or <br /> Joaqu Joaquininstall <br /> Countywork <br /> Ennvironmdescribed. <br /> ental Healh application ade in compliance with San <br /> Departme L <br /> Assessors �2d <br /> WELL Location <br /> 'A5L-)019 �/�} . Kayy) .r Cross street �t ity ` zip 015Parcel# 0 S <br /> 76 Tratxd a � 5acramP� gS8�8 v� <br /> PROPERTY y �-� - 7 <br /> Owner R' Address ' ' C16,' zit�Phone 07 <br /> SLq <br /> C-57 Contractor r Address C Ciry�'QiP � #� Phone# I .� �sa <br /> Consultant!Sub Cnt 12 v Address 1 C��.City > rc ic#�?4j3�j phone#q�• 2(01'Q4co <br /> C��}Sg NJ ,Townshi ?-N Range Section 1 <br /> GIS Coordinates:X (c44�n�E ,Y c2 GL7 i Township <br /> ___?=:N <br /> TO BE PERFORMED: <br /> XNEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> ;SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# a PRESSUR T <br /> Q*Other GROUT SPEI 10 <br /> u:w <br /> COMMENTS: , ..- h .. , L - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLES a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> j]EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL G PVC U OTHER: <br /> Q VAPOR U MUD ROTARY DEPTH OF GROUT SEAL_T TREMIE TYPE TO BE USED: Q AUGERS `NOSE <br /> AIR SPARGE/OZONE 9PUSH POINT(GP orPT)GROUT SEAL PUMPED:)[ Yes 0Noo .(.NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1 lY± <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS gtM/n Ili nAt'+�1Lt`L ,?Sa eL±1`y <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH JQ& MU BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 1 r ' <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Ll Title/Company-12@C 4 �11 <br /> Date <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: t- a Lane, <br /> WORK PLAN DATED: A r6o 4 <br /> Application Accepted By + i L . M G C-dr Date Issued 1 .zS Area 1 <br /> Grout Inspection By ��-fie.' mE Date -71),q d Final Inspection By c i7Y: nle ate 7 a <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: C G <br /> 7ACCOUNTING ONLY: AID# FAC# <br /> DES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 'r99.oa 89. Dd SV// 3 SR# 0038 S93 <br /> C-57J W(_-WAIVER— C-57 Letter of Authorization to sign permit„Encroachment doc— <br /> EHD 29-02-001 <br /> 9/30/2003 <br />