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Print Name 3. c ji1 t9
<br />DEPARTMENT USE ONLY
<br />Date 01- (03 c.)3
<br />
<br />SITE MAP IN UNIT IV FILE, ADDRESS:
<br />WORK PLAN DATED:
<br />Application Accepted By
<br />Grout Inspection By
<br />Destruction Inspection By Date
<br />COMMENTS I CONDITIONS.
<br />2003 Date Issued g 4A Area
<br />nal Inspection By Date
<br />WELL I--JRMIT APPLICATION FOSI
<br />SAN JOAQUIN COUNTY
<br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD)
<br />304 E. Weber, Third Floor, Stockton, CA., 95202
<br />(209) 468-3449
<br />
<br />
<br />SITE
<br />MITIGATION
<br />UNIT IV
<br />
<br />
<br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />Application is hereby made to San Joaquin County 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 Standardspf San Joaquin County Environmental Health Department.
<br />Assessor 's rdc-ikA... /4ve,
<br />WELL Location ti.Gc, PAlci6k.. igt," ve Cross Street CA3712_ -5T. City STPC, K. 70 .1-1 Zip Parcel#
<br />y Joy, or._ , , .4 „,
<br />PROPERTY Owner IMIQ ,0 Pk/ 11-i.. fc0,9+,,AP Address C . 8cic //c 7 City STCCK TOP) Zip/SZc-/ Phone# Q9) qt.7 PN/
<br />nA r ) ) ,
<br />C-57 Contractor PO i'/C,P)s2 ii el) / I ) 1).., Address 5560 S . tivirri /AA, City-54CAVY1Pi Aip955' ZG Lic# 6 7.7 L/ 7 Phone#@10 65 /-35.8:3
<br />Consultant/Sub Cntr 4,6 , E-- . Address 837 5H4v.,) RJ, Citysk.K ror, Lic# Cr..) dar2 Phone#(Z (i) V4 7- (no 13
<br />GIS Coordinates: X , Y , Township ,2 N..) Range 6 F Section (0
<br />WORK TO BE PERFORMED:
<br />ANEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") 0 DESTRUCTION (choose type below)
<br />0 SOIL BORING # 0 OVER-BORE
<br />"WELL # E kA,I- .1.e_PRESSURE GROUT
<br /> Grout Specifications: PQr7/e9 IN 40 ----17IN
<br />11-PPR D wur( gew .1)/ i -r-Q ) aci igpR ; L._ .:.?1 c., ,;
<br />"Other:
<br />COMMENTS 5
<br />
<br />TYPE OF WELL INSTALLATION TYPE
<br />
<br />.7CfMONITORING 74-1OLLOW STEM
<br />
<br />EXTRACTION 0 AIR HAMMER/DRIV
<br />
<br />VAPOR 0 MUD ROTARY
<br />fl AIR SPARGE / Ozone ['PUSH POINT
<br />
<br />0 SOIL BORING a HAND AUGER
<br />
<br />U OTHER: El OTHER
<br />*COMMENTS: S F-1- 09fP8kmD
<br />EN CASING THICKNESS 9 0 TYPE OF CASING: 0 STEEL PVC U OTHER:
<br />CONSTRUCTION SPECIFICATIONS I/
<br />DIA. OF BOREHOLE /5 " MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA: kJ'
<br />DEPTH OF GROUT SEAL VE 6-7-35 F7T'REMIE TYPE TO BE USE : AUGERS U HOSE
<br />S,..hviyvk
<br />GROUT SEAL PUMPED: es U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30')
<br />f ,rveiNn GROUT SPECIFICATIONS:
<br />APPROX. BORING DEPTH (05Fr. ,BOLTED TRAFFIC BOX or U STOVE PIPE
<br />A CONDUCTOR CASING PROPOSED? Al ( if YES, list specifications here):
<br />/it v ° dctiv , DINT) C) to /19z.%; Pon Z Do Z_
<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 certify that I have prepared this application and that the work will be done in accordance with San Joaquin
<br />County Ordinances, Rule and Re ulations, and all applicable Californ tate Laws,
<br />Signed x N Title/Company gc:JjE CT- kr...1/0 ,01- ieci,
<br />< •
<br />ACCOUNTING ONLY: AID#
<br />PE CODES FEE INFO AMOUNT REMITTED CHECK # R C' 'A' .Y d II DATE PE: .,iMl * E REQ • _..mrilliilidilftw.. INVOICE
<br />3501 5' 47 , 0 0 IR-8Y 5 yr cokizeo Q032- 3 3 Lf-
<br />C-57 WC -WAIVER C-57 Letter of Authogitio sign permit E 8/29/02
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