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REcENETELL ERMIT APPLICATION R&M <br />SAN JOAQUIN COUNTY <br />DEC, o3 2.111 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />r.:N\ivNivI EN'T HEALt04 E. Weber, Third Floor, Stockton, CA., 95202 <br />PERMITISEPMCES (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. <br />Assessor's <br />WELL Location A) E (-kW (S 2— Cross Street Gra2e-srl Vi 11- City \re,44,, __ <br />zip q523 Parce1# LS --Z )-40 -07- <br />C-57 Contracto <br />7 <br />Cdi CC& rig dreg,403:2 Z))" ee-- City-CLC- <br />Address .W 3 6- t-etkir )32_ city Vet^r, 6-,Inp•gss&c,Fhone# (5)(0/e}zo-: <br />Zip 95 1(ajc#7 17Si °Ph„e406 //69 <br />PROPERTY Owner " 4-449 <br />Address 037 SIVA") te )-City 577114/1 Lic# Phone# Consultant / Sub Cnir itIjc-66 .07-d 7,6) <br />GIS Coordinates: X Y , Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL] BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) eKESTRUCTION (choose type below) <br />a SOIL BORING # a OVER-BORE <br />fl WELL # Fj,=PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS <br />SITE <br />MITIGATION <br />UNIT IV <br />TYPE OF WELL INSTALLATION TYPE <br />OONITORING AfHOLLOW STEM <br />a EXTRACTION fl AIR HAMMER/DRIVEN <br />VAPOR a MUD ROTARY <br />1(1.1 AIR SPARGE I ozone a PUSH POINT <br />a SOIL BORING a HAND AUGER <br />OTHER: flOTHER <br />*COMMENTS: <br /> weff <br />CONSTRUCTION SPECIFICARONS <br />CIA. OF BOREHOLE 25 U..JLTIPLE CASINGS? a MULTI-LEVEL? a WELL CASING CIA: <br />CASING THICKNESS TYPE OF CASING: OSTEEL a P <br />DEPTH OF OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS HOSE <br />V; OTHER: <br />1] <br />i1):1 k.)) <br />GROUT SEAL PUMPED: a Yes a No (NOTE: M,AXIMUM FREE-FALL DEPTH IS 30') ill <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH pea-e-- a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? NtrA- ( 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 certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinan es, Rules and Regulations, <br />Signed x <br />Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: cag/S Phdkiy <br />WORK PLAN DATED: <br />, VC% <br />and all applicable Californi State Laws. <br />Title/Company — 6 <br />Date 1.60 7 <br />LAW O\ <br />Final Inspection By r.,,,V Date(.A./ <br />1-211-itiS?Au Application Accepted By <br />Date 1 2,41(n(D3 <br />Destruction Inspection By Date <br />Area <br />a t Grout Inspection By tittlAA,A.C4A. <br />Date Issued <br />COMMENTS / CONDMONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE EQUEST • INVOICE <br />e, SRP03 6 2- 475 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit ---Incroa <br /> <br />8/29/02 <br />