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San Joaquin County <br /> 2' Environmental Health Department SITE <br /> e• a <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> c _ P (209)468-3449 Fax: (209)468-3433 Web: www.co.san-joaquin.ca.us/ehd UNIT IV <br /> 1LiFORa <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 <br /> M County Environmental Health Department. <br /> Assessors <br /> WELLLocationSIO E. Cross Street City J-6--L4oin Zip 1,57-OZ <br /> Parcel# 139-ZID-off <br /> PROPERTY <br /> Owner CSI, Address qc0 <br /> 0802 Phone# 5(-2-'IS I-41z o <br /> � a- CityZip`) <br /> pertontractor COA0.0 r Address Civ. Str . 2 `+SZa.Lic#_RA_Phone# 209-23 -0518 <br /> Consultant/Sub Cntr Address ,, 11 CityUc# Phone# <br /> GIS Coordinates:X ,Y ,Township e-r 41. Range (o 6Q 5 't- Section Z. <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0.Other / GROUT SPECIFICATIONS <br /> COMMENTS:I••• v ara.d Intel¢-5 -+'D 2-Feg- eY' S--(V2t <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING p HOLLOW STEM DIA.OF BOREHOLE 22' p MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS t!A TYPE OF CASING: O STEEL 0 PVC 0 OTHER: _ <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL IELFr TREMIE TYPE TO BE USED: 0 AUGERS_ 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes�0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING NAND AUGER GROUT SPECIFICATIONS II& <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH T -1 S' 0 BOLTED TRAFFIC BOX or. 0 STOVE PIPE <br /> /•CONIDUCT`O/fit CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: �7 K �25 �1 4 S T-II2�I 7 T 0 "I'O <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 Ordin ces, u1 an Reg tions,and all applicable California State Laws. <br /> Signed x I Title/Company (fo n a�o r - T.Zc.tn..l�o/o IAC . <br /> Print Name i LC-IG.0. ln-a.- Date -4 (o O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 5 + 6 <br /> WORK PLAN DATED: I ��3 I q [[ <br /> Application Accepted By Date Issued I (] T Area_1_1:1/ 2-- <br /> Grout Inspection By Q�U&Dat�e �Inspection By Date_4/I2/� U <br /> Destruction Inspection By ._ ` _ / <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERV7;7E]a`1 -2 sR# 3 ? <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 />