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San Joaquin County <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 9520�IGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.Sigov.org/ehd UNIT IV <br />FEB) 0 `; 2005 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Fi ` 'IRON � NT HEALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described �q (�,atijetj�;gnade in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental WAalt}� D'ephttm6rrt <br />Assessors <br />WELL Location'30,1 6L' (i2o„N,y�,l9 %llZ�� 7;�� Z Cross Street&"'3„' Atict-- City,yjy �- f2 Zip'15�Parcel# <br />PROPERTY <br />Owner 1; C Address RY57 're”; H Su lu Lt City i n Zip ` `J'= /`/ Phone# Zc�-1 - 95- 7 <br />p -,s53 <br />,j D. -')65C-57 Contractor (oD.-')65Address `/SZ rh.,,tit'_ �� City,�'� r Zi Lic# c��/��hone# �JZj--3��.-j�;•G <br />nsultant / Sub Cntr G'tfj?,vA $�h,,, ro,�,xe�+ �ddress 2. 4, �i r� h 7f City S n Yv�ti Lic# ti 4Phone# 7C - <br />i n ' <br />GIS Coordinates: X ti ��, Y Township 1 Jv Range Section <br />WORK TO BE PERFORMED: <br />-NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />WELL #A,4 1A) -i -27 0 PRESSURE GROUT <br />0 "Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />'"ONITORING P,�9OLLOW STEM DIA. OF BOREHOLE' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS(;( TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL - - Ei TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes EpWo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0SOIL BORING 0HAND AUGER GROUT SPECIFICATIONS - \r:v�r� _ �re�lC�df 04- 3%?Pj+t4r* <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 2S �)LBOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED %1 C-1 (if YES, list specifications in comment section) <br />COMMENTS <br />NOTE: OFFSIT"ORINGS 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 work will be done in accordance with San Joaquin <br />County Ordin_qnr <br />pqsjutgA,jnd Regtrjations, and all applicable California State Laws. <br />AX 10-A <br />Date <br />Print Name I <br />�. <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: DPS <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Insoection B <br />COMMENTS / CONDITIONS: <br />Date Inspection By <br />2 - 2- Z '—O'5 <br />Date <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P VIC EST # <br />INVOICE <br />MVS <br />SR# 2� <br />C-57 ✓ WC= WAIVER_ C-57 Letter of Authorization to sign permit J Encroachment doc okf­tl <br />EHD 29-02-001 <br />9/30/2003 <br />