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Date Issued .31 '410.3 Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Area <br />Final Inspection By (45..t.14.te-c-1 Date 3/2-8103 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED rh <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicAbiviRW Y-Lth San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health DepaRERMIT/ r <br />Assessor's <br />Consultant/Sub ContractorGrOUrld Zero Addresi 714 Main St. cir,Esca1onLic#5023 Phone# 772-3570 <br />GIS Coordinates: X Y Township Range (#,E (iRsia) 838-9888 <br />WORK TO BE PERFORMED: <br />UNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # 1 <br /> <br />0 WELL # <br />*Other: <br /> <br />Grout Specifications: Neat <br />COMMENTS: Borings to 25' depth <br /> <br />fl DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br /> <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />.11 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2" MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: W <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL El PVC 1:1 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE (.1, <br />0 AIR SPARGE XDIPUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />)SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS' <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 25' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if,YES, list specifications here): <br />en r ( V\ 4-o ,6 e. Co re\ li). I e-4 -e 8 4ts s rn cl GO Octe..C. <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 Ordinance , Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company 6 VON--A, -e&'0 A`^c&1Y St S, 12-67 <br />SITE <br />NHTK14TRYN <br />ru OTTW <br />MAR 1 2 2003 <br />WELL Location 530 E. Market <br />AddressP.O. Box 900 city Stockton z95201 P14)9) PROPERTY Owner The Record <br />Valley C-57 Contractor Fi sch Env. <br /> <br /> <br />45;8)361 <br />Address 399 Sheris Pl. City SpringEP 9 5252c#683865hone#5 <br />(20 <br /> <br />crossstreetCaliforni,ty Stockton zip95202 Parcel# 149-130-18 <br />*COMMENTS: <br />Print Name Jo Lv‘. Lckvve_ Date 03//r/o 3 <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 5 3 0 •E... frna.A.ke* 5 47,-C—k-,6.-"-1 <br />WORK PLAN DATED: Pin \ D3 <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE QUEST # INVOICE <br />3 56 ( T1 tp '11 1a-3c-a 3113)03 -O3°52 <br />-WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Erhnriir 1/25/02 C-57 C-57 WC