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03/01/2005 11:52 2094SR3433 FIFTH FLOOR PAGE 03 <br /> 041! JIDLt4ullo I—UTAAAl.v <br /> 0LM &nmiental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (TR'�438�34407ax; (209)468-3433 Web: www.co,san-joaquin.c1-us/ehd UNIT IV <br /> R, POM- W46WABLE PERMIT(EXPIRES 1 YEAR FROM DATE ISSUED <br /> �Cnpp�I-r SFSLS <br /> Application Is hereby mad 15'San Joaquin County for a Permit 10 construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Davoioprnent Title,Chapter 9-1115,3 and the Standards of San Joaquin County Environmental Health Department. <br /> 'I <br /> WELL Location�y` I"lp A/ _Cross Street 6g.// City-y, Mj S Assessors Zip /5 parcel# AJA <br /> PROPERTY /(J� <br /> Owner. **_� //e•idress)'�74CifYy st -Zip�Phone# <br /> '��QQ / - <br /> C-57 Controctor.Aus.-'4 -5—' R'1 rA�lddress 10,61 five City �1�+ma� ip_j&!4Lic#j63MPhone#,A[r_Z_37'Y,�y� <br /> Consultant/Sub Cntr lee_ Address CityJAcl---& Lids Phon.#_� <br /> CIS Coordinates:X ,Y Township Range - _ Section. <br /> WORK TO BE PERFORMED- <br /> [I NEIN WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION (choose type below) <br /> 9.$OIL BDRING# _Sn t'7 Q OVER-BORE, DIAMETER <br /> 0 WELL k. Q PRESSURE GROUT <br /> Q*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF Vlf>'LL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE <br /> _Z LI MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:�� <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS_&i Aq-_ TYPE OF CASING Q STEEL LL PVC <br /> Q OTHER: <br /> a VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 4t+k( TREMIE TYPE TO 13E USED: QAUGERS HOSE <br /> Q AIR SPARGE!OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: d Yes 'xNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> `SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS :k <br /> !/a OTHER:_g OTHER APPROX.BORING DEPTH �r� <br /> LJ BOLTED TRAFFIC BOX or LJ STOVE PIPE <br /> CONDUCTOR CASING PROPOSEo__,_,_-1 (it YES, listspecifiCations in comment section) <br /> COMMENTS: 07 <br /> NOTE: OFFSITE BORINGS REQUIREACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> I hereby certiffy that I ave prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinance Ids and Regulations,and all applicable California State L ws. <br /> Signed x TitrelCCmpany <br /> Print Name r I n S Dae� <br /> DEPARTMENT USE ONLY <br /> SITE MAP 1N UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED• <br /> Application Accepted By46k;,±� Date Issuedfl5-' Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: d7 F,w r/ ('0 1 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 WC`WRIVER_ C-57 Letter of Authorization to sign permit Encroachment dac� <br /> EHD 29-02-001 <br /> 913 0/2 CO2 <br />