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OrLL PERMIT APPIAC ,,TaON FSM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENTd UNIT IV <br /> FEB 14 2002 304 E. Weber, Third Floor, Stockton, CA., 952 <br /> (209)468-3449 <br /> Application is hereby made to San Joaquin County for a permit NON- o construct and/ori EFUNDABLE stall the work orfs d schb FROM DATE. This tions made in compliance with San Joaquin County <br /> Development Title,SC <br /> I hapter 9-1115.3 and the Standards of San Joaquin`County Environmental Health Department, <br /> WELL Location 1 1 l 1 ,� Cross <br /> LStreefft] City�T /► _ZipParcel# Q' Assessor's <br /> PROPERTY Owned i1 .Address 7� >Y 4. S City s Z,iP�, Phone#C�7 7-y <br /> C•57 Contractor r SCity ff- Q,7<, <br /> Consultant!Sub Contractor 7 6_� Addres G+ � <br /> © 7 itY�"�74ic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> W92K TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> ,,]1OIL BORING# []OVER-BORE <br /> 0 WELL# i]PRESSURE GROUT <br /> "Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE !4'd MULTIPLE CASINGS?0 YES,6'NO WELL CASfNG DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEIPVC 0OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL S T�E_MMII}E 4 PE TO BE USED: )J.ACGERS [I HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Y.s —0 N.-%6TE: INAXIMUM F EE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS; �"+�" t��L -T <br /> []OTHER: 0 OTHER APPROX.BORING DEPTH OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> FZSCONDUCTOR CASING PROPOSED. (if YES,list specifications here): <br /> `COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> Rules and Regulations,affn�djj all applicable California State Laws. <br /> Signed x r!�(1f.{g,��_ A.[ _ Title/Company <br /> Pnnt Name L'O' // ti �- 7n,0— Date / d� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: C�7 I Q <br /> WORK PLAN DATED: <br /> Application Accepted B 'V�ct C. Date Issued, 1 , �00Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# #�161YPATE PERMIT!SERVICE REQUEST# INVOICE <br /> 10 3l SR# <br /> C-57 WC -WAIVER C-57 Letter of Augn permit Encroachment dccJ 1/25/02 <br />