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07/19/2002 08:18 2094683433 FIFTH FLOOR PAGE 02 <br />WEL91PERMIT APPLICATION ARM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468.3449 <br />SITE <br />PAJTIGT <br />NOV 1 3 2002 <br />NON-REFUNDABLE PERMIT EXPiRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is rrPligk;�I LkS San <br />Joaquin County Development Tete, Chapter 9.1� X1155 and the Standards of San Joaquin County Environmental Health Department, <br />�(n� CWELL Location � Cross Street ityzip. <br />PAasrcseels#sors <br />i dao `AZ <br />I <br />�)tE;N <br />PROPERTY Owner T" uF �T�k�7+J Address �I . sem�City[XJc�r 2ip�Phoneff 4q <br />�J9'�� <br />C•57 Contractor �lur� ti. EKET SZ -City �.I►wr,Zip`�Sr►E,Uc g[r{33y Phone# O <br />r Address ( 4 - "U- '1 <br />Consultant! Sub Contractor 092 dress SDO 10 UcX Phon `L�9 <br />CIS Coordlnates: X Y , Township Range Section <br />WO I TO BE PERFORM D: <br />AID# <br />EW WELL �. ORIN <br />'Other: <br />COMMENTS: ITP—Do- <br />CPT, GEOPROBE, YDROPUNCH AND -AUGER. OTHER-) Q DESTRUCTION (choose type below) <br />D SOIL BORING a OVER -BORE <br />n WELL#_ a PRESSURE GROUT <br />Grout Specificatlons: <br />T—DjTYPE <br />FEE INFO <br />TYPEOF WELL <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />REC'D BY <br />p MONITORING <br />n EXTPACTION <br />(1 HOLLOW STEM DIA. OF BOREHOLE i -5 , MULTIPLE CASINGS? 13 YES (ANO WELL CASING DIA: NZ7 <br />FAIR HAMMER/DRIVEN CASING THICKNESS Iur) TYPE OF CASING: Q STEEL 11 PVC [I OTHER: <br />i] VAPOR <br />0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: *0AUGERS JtHOSE <br />rp <br />I AIR�SPARGE <br />I OIL BORING <br />0 PUSH POINT GROUT SEAL PUMPED: Q Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30`) <br />n HAND AUGER GROUT SPECIFICATIONS:_ <br />!1 OTHER; Fr6THER <br />'COMMENTS:�r <br />CMPRCOC qw� APPROX. BORING DEPTH. O BOLTED TRAFFIC BOX or Q STOVE PIPE <br />CONDUCTOR CASING PROPOSED?_ lji�, (if YES, list speaficatlons here). <br />�6S_ Q" f1CF_; j1E=�^CSGA��J <br />DOTE: <br />OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />c;ALL THF IINIT IV INSPF-CTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ord ina n c , R1L, ps and Regulations, and all applicable California State Laws. <br />Signed x �n•._ Title/Company�It�rF�- r G51/ 3z/r 1��5 <br />Print Name Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS <br />WORK PLAN DATED. �/ <br />Application Accepted By f 1 Date Issued r��-/0 ' ' - —Are"��� G2 C rS <br />Grout Inspection By Dal OZ -1 Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMffTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT/ SER91CE T # INVOICE <br />a6l; <br />s :Z`1 <br />14T- <br />11 r� <br />r � slrx� U 3 � <br />C-57 WC_ --WAIVER C-57 Letter of Authorization to sign permit c 1/25/02 <br />