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* L <br /> San Joaquin County <br /> SITE <br /> Environmental Health Department JUN 2 2 2004 <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 9 MITIGATION <br /> ' ' f (209)468-3449 Fax: (209)468-3433 Web:wwwsjgovr R NMENI HEALTH UNIT IV <br /> g.;F..r . � AT/SERVICES <br /> ;r� ,, <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 Devel pment T le,j1ar 9-1 15.3 and the Standards of San Joaquin County Environmental Health Department.L �, ':�'5R 330-0 <br /> Assesso <br /> WELL Location ros tree City Zip�l ✓�"r"" Parcel# 59- 3 yo-1 Z� <br /> 1� <br /> __rr r� QC � :Sl(c�tS R,'J.Yit _ �/q!p p <br /> OwnRTY <br /> erEQat'f k Ci nnC,n.LC` Addressr�t59 N. LL 1�,,//�VU ccciity�y�_zIip�-a3--( onee##�1 <br /> C-57 Contractor__�.to.nf i`�Y�1� _Address[7u�"' N,C PG+ J 1. LCi yI&lajip R tic# O�P�h ne#✓c3�'liAoC,,C� <br /> Consultant/Sub Cntr C� Address � l• r�t �AD�S4Li(dF� // Phonetl5/o'� aSJr� <br /> GIS Coordinates:X ,Y - .Townships Range 'K l- Section_ <br /> WORK TO BE PERFORMED: <br /> D NEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER*) D DESTRUCTION (choose type below) <br /> D SOIL BORING# D OVER-BORE. DIAMETER <br /> a*Other# M - .iQ�y l l A1` <br /> _ a PRESSURE GROUT <br /> * <br /> D OtheGROUT SPECIFICATIONS - <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ra N <br /> MONITORING D HOLLOW STEM DIA.OF BOREHOLE ULTIPLE CASINGS D MULTI-LEVELr,t WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMERIDRIVEN CASING THICKNESS5c' Nnh 4o TYPE p LOF CASING: D STEEL ,pjPVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 2' ,iC-S TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTES ImoRE; F -FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS nr-kQ <br /> D OTHER: fl OTHER APPROX.BORING DEPTH �j r D BOLTED TRAFFIC BOX or kSTOVE PIPE <br /> ��X) 1CONDUCTOR CASING PROPOSED (H YES,list specifications in comment section) <br /> COMMENTS:TWO [ 1 61QD IAO; hlit k+Lb, (229U IL(-(1 , Q E�f7 1 V <br /> -oro I-a1 ok- woks <br /> NOTE: OFFSITE BORING 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.00rrdyinnatncc'es, Rules and Regu'latiign/s,,and all applicable California State Laws. <br /> Signed <br /> /� yI <br /> Signed x y ' 1 � M G U /W`ice• ' Title/Company V \ KV C - <br /> Print NameLJ i 7.1 _l' _Date r5 ��- <br /> DEPARTMENT USE ONLY I 3C� 6 b! t, <br /> � x��r35 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3� �r I G 1 al-� —166) <br /> WORK PLAN DATED: <br /> Application Accepted By�,,p / r 1 lT��'Y`r "�-11' Date Issued b " y Araa � ry <br /> Grout Inspection By �'Ir\ a 4�'�t ate I I�I Final Inspection By Date / <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: I l � n e5 c 0.•C <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT]SERVICE REQUEST# INVOICE <br /> SR# 3�5� <br /> C-57 W(_--1 WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> 9E}HD/29-02-001 1.--- <br /> M� I&3 ? <br />