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113111112005 11:52 2094683433 FIFTH FLOOR PAGE 02 <br /> San Joaquin county <br /> ronmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> F(2694 ����9�� Fax:(209)468-3433 Web:www,ca.san-joaquin.ea.us/eiid UNIT IV <br /> J'R0N '1-4TT�VsRE ADA1aLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin CorJnty 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 County Environmental Health Department. <br /> Assessors <br /> WELL Location _ Cross Street City rv.<<5 zip'7f3gS Parcel# 5K 11- <br /> PROPERTY ! <br /> Owner ,1 Address ebb I t.11 _ _City['Yg,;jAo Zlp hone# <br /> C-57 Contractor AcuaraA _ .�,/�Mt_ ddress ( ��:�ily&4w ip1L1c#�%Phone#5r4-Z <br /> r� <br /> Consultant/Sub Cntr Address Mfi4 iG �W1[aCity (witl � Phone# ���9 <br /> GIS Coordinates:X Y Township_3 S Range 6 Se�iion <br /> WORK TD BE PERFORMED; <br /> NEW WELL I BORING (CPT.GEOPFtOBE,HYDROPUNCH,HAND-AUGER,OTHER') .-,&4) (chooso type below) <br /> SOIL BORING$ 5 F 5(�„r S �15�SI3-1$ [OVER-BORE. DIAMETER <br /> !L# • f_ M p PRESSURE GROUT <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: — <br /> TYPE OE WFLL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS A <br /> KMQNITORING XHOLLOW ST DIA.OF BOREHOLE Z r• p MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA Nfii_ <br /> p <br /> EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESSHYPE,OF CASING: p STEEL Q AVC BOTHER <br /> VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED, n AUGERS OSL <br /> p AIR SPARGEI OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: R Yes ).(No (NOTE: MAXIMPM FREE-FALL DEPTH 1.9 30) <br /> SOIL 130RING p HAND AUGER I - GROUT SPECIFICATIONS <br /> (]OTHER; Q OTHEIxG APPROX.BORING 17EPTH <0 f f Q BOLTED TRAFFIC SOX or p STOVE PIPE <br /> } { YiA21S CONDUCTOR CASING PROPOSEI]._ ���(if YES,list speeificalinns in comment section) <br /> CONTINENTS' �fJp✓ a 12 r� rr A, `� O <br /> NOTE. FFSIT BORINGS REWA* ACCESS AGI EEMEiVT OR ENCROA&A4MET PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. `' n <br /> I hereby certify that I have prepare this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, les d Regulations, and all applicable California State Laws. <br /> Signed b Titlelcompany �" G <br /> Print Name A.!-> Dare <br /> DEPARTMENT USE ONLY T. <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED11.Z1 P If: <br /> Application Accepted By __ _ <br /> _ _Data Issued -311 0 Area 1 c17 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS.. �a J <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> t41 ��' �' COO/ 1 73l D� SR#0 12 ! Io <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 />