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r <br /> "an oaquin County <br /> i Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202JUN 2 3 2004 MITIGATION <br /> ' F (209)468-3449 Fax: (209)468-3433 Web: www.co san-joaq c u /�hd UNIT IV <br /> � . . <br /> A <br /> 4�P 'i U 1V1 NT HEALTH <br /> u��¢ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE issd%Rf /SERXE <br /> I <br /> Application is hereby made to San Joaquin Countyfor a permit to construct andlor install tha 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 County Environmental Health Department. <br /> .y� yy Assessors <br /> f WELL Location k. HF' r` <br /> ID <br /> Cross Street t/"��� ity t7wl Zipl Parcel# a D30 <br /> WELL- —I <br /> • r <br /> PROP <br /> TY <br /> r ownerER 0' Address ?� SIJ City !"+ �_ -`Z �J3G Phone# J rZ <br /> C-57 Contractor t �0-it' Address a� �+�'■ /City �LVLVzip r Li1f47z61 Phone y[} DJ <br /> Consultant/Sub Cntr_fitt7T Addressj ?i7 1(�^� Kai ity�t ic6 ga/2� Phone# G D I lwV j <br /> I <br /> GIS Coordinates;X Y Township Range Section <br /> WORKTO BE:PERFORMED; <br /> n NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose type below), <br /> p SOIL BORING# >OVER-BORE. DIAMETER%.35 <br /> o WELL# a PRESSURE GROUT <br /> U*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL JVA INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> fl MONITORING a HOLLOW STEM DIA.OF BOREHOLE o MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:__� <br /> p EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC q OTHER: <br /> q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br /> ©AIR SPARGEIOZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_9 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS., <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 wor, will be done in accordance with San Joaquin <br /> County Ordinances, Rules af Regulations, and all applicable California State Laws. p� <br /> Signed x TitlelCompan <br /> Print Name d �a a✓t Date_ tl `�31C�7 <br /> DEPARTMENT USE NLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 0 aUD <br /> Application Accepted By ' t✓ '" ed D <br /> i <br /> Grant Inspection By Z Date Final ow ection By <br /> Destruction Inspection By Date <br /> COMMENTS ICONDITIONS: VA& <br /> ACCOUNTING ONLY: AID# FAC# It QL <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUES #Q E <br /> ,q r ZVI sR# <br /> C-57 WC_,.,^WAIVER_ C-57 Letter thf-7– <br /> o si typ�it Encroachment doc___ <br /> $HD 29-02-001 <br /> 9/30/2002 + <br />