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aQ.U!N. uin'Conn FILE C <br /> n Joa <br /> o e tl t' <br /> °U ECE "nmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> N;'/A(f09)-4�fi49 Fax: (209)468-3433 Web: www.sjgov.org/chd UNIT IV k <br /> Coq �4 f <br /> R ENVIRONMENT HEAII Permit Application <br /> PERM 01, RVICES <br /> O -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> plication 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 /> 3quin County Develooment Title,Chaoter 9-1115.3 nnri the Stand:rds of San Joaquin County Environmental Health Department. <br /> 144. <br /> Assessors <br /> JELL Location Cross Street Nnv CityI— _ZipC1S 3 Parcel#Zf ! !Z r <br /> ?OPER S d l�` Address�� 1. G ry n� Zip l �-"/ Phone# <br /> wner� C vt;r� ty <br /> 57 '_1Contractory��E Address Z JIe.4c(k. t.� L1,C City 2 Ziprr �L'Ic# � Phone/� 5 65 " 7 41 <br /> / lrCc.nel;e <br /> ')nsultant/Sub Cntr L, �, � (i��s✓� Address C��4e City-PL, .:n Lic# Phone#9Z✓ -'t Z� <br /> 5.e/rV CS R-- s t— tic. �> <br /> , ✓-t,c;S Coordinates:X 4 3yYl 2!` �Z r jar Township e6- Range k Section i <br /> 70RK TO BE PERFORMEDs <br /> ANEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> ,&SOIL BORING#3 Z 53 0 OVER-BORE. DIAMETER <br /> 0 WELL# —� 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> ;OMMENTS: <br /> Y_ PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2- 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ^/<� TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ,��t� TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> i AIR SPARGE/OZONE j3-/PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0//No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS]?{)?�tz,- t 6 <br /> OTHER:_0 OTHER APPROX.BORING DEPTH 3,:2 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED V\ e� (if YES, list specifications in comment section) <br /> .JMMENTS: <br /> i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> ^ereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> .ounty Ordinances, Rules and Regulations, and all app+icable California State Laws. <br /> igned x -- — Title/Company S I s / �" `7L <br /> o 1-. . ,• <br /> rint Name C✓ 1 L �� _Date <br /> DEPARTMENT USE ONLY A �� <br /> ;ITE MAP IN UNIT IV FILE, ADDRESS: <br /> YORK PLAN DATED: �� 2 N <br /> ,pp!ication Accepted By Date Issued J�I S Area <br /> ,rout Inspection By Date Final Inspection By Date <br /> )estruction Inspection By Date <br /> %MMENTS/CONDITIONS: <br /> '.0000NTING ONLY: AID# FAC# <br /> "E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> �q o 1 �� 8'�, 2 � Com. 3- IsR# <br /> -57 WC -WAIVERC-57 Letter of Authorization to sign per En�Cre�ment doc / <br /> :HID 29-02-001 <br />