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Area <br />Date Ait•C <br />Date <br />Date Issued kl I /o/ <br /> Final Inspection By t/t S-4.4A./1( Date <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS. <br />-//e <br />wpi pERMIT APPI IrAT1ON FoRio. <br />9 2.00 1 - 4.4 SAN jOAQUiN COUNTY PUBLIC HEALTH SERVICES <br />EwBoi\NEw-c ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />pERMaiSEB\I Ut \L, s c-4209) 468-3449 <br />Sd <br />1..Kci) A NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />pplication is hereby made to San Joaquin County tot- a 7,,onnit to construct and/or install the work described. This application Is made in compliance with San <br />)oaquin County Development Title. Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location J:4(4 Cross Street lc/ e 2-- City57:T Zip <br /> AssesSor's <br />Patoet# <br />,ROPERTY Owner_ &- k•-•6- ICIatAr4-4dress <br /> <br />(16 (7 ,cc(c city Zip 7SZc3Phonel <br /> <br />%EC ITC %/a I 1_ <br />MITIGATION <br />UNIT IV <br />Address City Zip Li Phone; <br />:onsultant / Sub Contractor /4 ,:-,,/ Address City Lic# Phone# <br />, 3IS Coordinates: X Y , Township Range Section <br />WORK TO RE PERFORMED; <br />I NEW WELL / BORING ( CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') U DESTRUCTION (ChOOSa type below) <br />A-SOIL BORING # 0 OVER-BORE <br />(3 WELL # 0 PRESSURE GROUT <br />'Other: Grout Specifications: <br />:OMMENTS: <br />Contractor <br /> <br />fYPE QF WELL INSTALLATION TYPE <br /> <br />] MONITORING U HOLLOW STEM <br /> <br />] EXTRACTION a AIR HAMMER/DRIVEN <br />VAPOR QMUOROTARY <br /> <br />] AIR SPARGE .,03)USH POINT <br /> <br />ASOIL BORING U HAND AUGER <br />OTHER: 0 OTHER <br />'COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES U NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL U PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS U HOSE <br />GROUT SEAL PUMPED: U Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby ce ify-that Hiave prep d this application and that the work will be done in accordance with San Joaquin <br />County dina Rules a bons, and all applicable California State Laws. , <br />' <br />/C't v9Ze.//,/ J .: C M-I--II--/y Signed Title/Company <br />Print ,--1-/._/- `"-X-'(//0,- -71-r Date 27;2-7/62/ <br />, <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />ACCOUNTING ONLY: AID# Eel <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERM EST # INVOICE <br />( c6,11.0... 00 551 2 td ql ('/ <br />C-57 <br /> <br />WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit_ <br /> <br />GROUT SPECIFICATIONS: <br />9/27/00 <br />