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}� � 0,\0 �� ter? <br /> : :. San Joaquin County LL' <br /> ->•_«>...>. :<>:<.> :>.... Environmental Health Department JUN 2 2 2004 SITE <br /> MITIGATION <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 9 �V R I JMEfdI f1i pLTH <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.or UNIT IV <br /> IT/SERVICES <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 Devel pment T'le, hapter 9-111115.33 and the Standards of San Joaquin County Environmental Health Department.l� r"C1` �1 Q��( , Assesso WELL LocationFfA M O) ros Stree City `1 Zip 1 ' %- ' Parcel# 5q- 3 yo-1 <br /> ivR-ou �tcc :StaS �z.�� �j�� <br /> PROPERTY c J� N. I q53 Rhone# � (-ca'OS <br /> OwneEontratct �g <br /> i pGnl. Address14 City�(Zip , v� tC-57 D-(N r".�Yt _Address t "�' � �� City u,M LV l'Zip "l Lic# 9)04 one# <br /> Consultant/Sub Cntr r/1 0A Address �• ��ty`j�J �+Lic# Phone#5l 0-62Z- <br /> ­7 <br /> 62Zad <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> o SOIL BORING# a OVER-BORE. DIAMETER <br /> a PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> 0.Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> WMONITORING a HOLLOW STEM DIA.OF BOREHOLEjW&OULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS. N 4/] TYPE OF CASING: a STEEL PVC a OTHER: <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL'glp�CREMIE TYPE TO BE USED: 0 AUGERS Q HOSE <br /> a AIR SPARGE/OZONE [I PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE' MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS ho (�L i>tc <br /> Q OTHER:—O OTHER APPROX.BORING DEPTH aQj ]' a BOLTED TRAFFIC BOX or ffiTOVE PIPE <br /> _ CONDUCTOR CASING PROPOSED N 0 (if YES,list specifications in comment section) <br /> COMMENTS: I I�%O I ) 1 '' Nt 9 Qi � t <br /> NOE: OFFSITE ORINGiREQ RE�ACCCESS AGREEMENT OR ENCROACHMENT PERMITS.`�V� <br /> NOTE: FS <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 /> Count Ordinances, Rules and Rengulatiio�nss,, (qnd all applicable California State Laws. <br /> Signed xl�m �� C l� uo u(—\ ' Tirle/Company <br /> Print Name \ )(J►�J �� +�lC�� Q��l Date �.� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: -)L( U <br /> Application Accepted By - Date Issued <br /> Date <br /> Grout Inspection By ti "ate—/ Final Inspection By <br /> Destruction Inspection By Date <br /> Z <br /> COMMENTS/CONDITIONS: 1 J <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> , 10 t gc 'f 1��3 in - G as1 o sR# <br /> C-57_ W(;---WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/30/2003 <br />