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's I <br /> ELLt RNIIT APPLICATION F( :M <br /> SITE <br /> MITIGATION <br /> W'MONTIC- <br /> SAN JOAQUIN COUNTY <br /> DEC 0 3 Z043 UNIT 1V - <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> tN� HEAL 64 E. Weber, Third Floor, Stockton, CA., 95202 <br /> 4NV1 �7NM� (209) 468-3449 <br /> Q��M1��SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 /> :aquin County Development-rite,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Dep arlment-Assessor's- - <br /> � Z Cross Street Vi(t City ��� �;�5 7ip�S�SParcet# Li'5-Z a0-'P} <br /> ELL t_ocation & <br /> �OPERTYOwner l 14-1.1 1)h Address '3 & + City 2l�-t^ riper_ hone <br /> �i O <br /> i Y'� U1� dres �n3'C��m�G CityS2� zip LyAil#?r�s,>�Phone ,l� t �116� <br /> -57 ContraC'o P / /� ll?w� <br /> onsultartt/Sub Cntr <br /> /�6 Address03'7 S�")i"ekCity.J I6�4 Lic# Phone# �� �6 <br /> Y Township_______________L Range Section <br /> IS Coordinates:X � /' <br /> 'ORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH;HAND-AUGER QTHI*R") ` 1]OVER-BORE <br /> 0 SOIL BORING# RESSURE GROUT <br /> 3ttter. O.W ELL# Grout Specifications: pe+, <br /> OMMENTS <br /> YPE OF WELL. INSTALLATION TYPE CONSTRUCTION SPECIFICA ONS <br /> �iIONITORlNG ��klOLLOW STEM D ��` sIA.OF BOREHOLE LTIPLE CASINGS?a MULTI-LEVEL?a WELL CASING DIA: N� <br /> EXTRACTION fI AIR HAMMER/DRIVEN CASING THICKNESS '� TYPE OF CASING: STEEL Il PV�OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SF_Ai- "� TREMIE TYPE TO BE USED: AUGERS a HOST= <br /> AIR SPARGE 1 Ozone a PUSH POINT GROUT SEAL PUMPED: p Yes 0 No (NOTE IMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: - G <br /> OTHER: d OTHER APPROX.BORING DEPTH .`i II BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?„�'f (if YES,list specifications here): <br /> COMMENTS: "l e <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 /> hereby certify that I have prepared this application and that the work will be done in accordance with'San Joaq <br /> :ounty Ordinan es, Rules and Regulations, and all applicable Califarni State Laws. ♦` <br /> r �-- "C �� GS� <br /> iigned x // Title/Company � <br /> Tint Name LSC Date -� <br /> DEPARTMENT'.USE ONLY <br /> 31TE MAP IN UNIT IV FILE,ADDRESS: <br /> NORK PLAN DATED: <br /> application Accepted By Date Issued 7r d Area <br /> Grout Inspection By —Datd464i�:e Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> P7;CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT l SERVICE REQUEST# INVOICE <br /> 3�0Z- (gyp.O c� / (vd ! �f o 3 6 Z.G�5 <br /> C-57 WC -WAIVER G57 Letter of Autharization to sign permit Encroachment doc * , 8%29/02 <br />