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WprIL PERMIT APPLICATION FORM <br />ti\mostAEN )1 , tLP\ SAN JOAQUIN COUNTY <br />Str,' ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />nu 3pif. Weber, Third Floor, Stockton, CA., 95202 <br />03 jus —2 rn (209) 468-3449 <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 Standards of San Joaquin County Environmental Health Department. Assessors <br />WELL Location 0 iCt.5 1- L2 IL.C.44 Cross Street it PDC tt...t City IC;,CA,) Zips kb Parcel# 2.'33 —369 -22. <br />PROPERTY <br />Owner 562. Address 1RD E01-5A 51; arn 3 tO0City Sfrft RaiYVA Zip 9(f553 Phone# 9 2'55 13 $666 <br />C-57 Contractor 6a4,(31 01 Dell‘,nal Address 0150 40tJt. PC' An City 4-C1\ t)(.,,S Zip q951-53-ic#11biStclphone# q2.5.3135-800 <br />- <br />ort:dt-Thant ub Cntr 56,...) 5:noirointyitor2A Address 140051r a ICO-f CityCO MAW Lic# Phone# q 2-52,n 2103 <br />--- <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />13 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING y I] OVER-BORE. DIAMETER <br />f). WELL # ; ''.1 - 1-,1 .3— 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />:11 MONITORING yl HOLLOW STEM DIA. OF BOREHOLE , , 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />11 <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 2_ TYPE OF CASING: 1:1 STEEL 11PVC a OTHER: <br />0 VAPOR 1:1 MUD ROTARY DEPTH OF GROUT SEAL (2 1 TREMIE TYPE TO BE USED: 1:1 AUGERS r] HOSE <br />0 AIR SPARGE/ OZONE 1:1 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING fl HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: ['OTHER APPROX. BORING DEPTH le-3 1 0,BOLTED TRAFFIC BOX or [I STOVE PIPE <br />CONDUCTOR CASING PROPOSED A.)0 (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS 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 d Re 'ons, and all applicable California State Laws. <br />Signed x Title/Company qpwre rtt-v;1., /?7,/, a., ee <br />Ch f erYerte/- Awl Oc- <br />sifIR I GINA L <br />MITIGATION <br />UNIT IV <br />Print Name <br />Date <br />DEPARTMENT USE ONLY <br />s-/•=o/o3 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />/6 f. <br />COMMENTS / CONDITIONS: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date 7 <br />Date <br />Date Issued <br />Final Inspection By <br />ACCOUNTING ONLY: AID# F AC# <br />DATE <br /> INVOICE <br />350 <br /> HYok- <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY <br />6-1 SR# 0/03y1/4 <br />-E-ncroachment doc - 9/30/02