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San Joaquin County REcEllm <br />D jhyiropmental Health Department <br />NT <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />HEALTH <br />_ ITE <br /> <br />(209)4N314$FgO0C09) 468-3433 Web: www.co.san-joaquin,ca us/ehd UNIT IV <br />ENviR MitftrillaltMPERMIT EXPIRES 1 YEAR FROM DATE ISSUEDPER <br />tivvji:Ni :ITIGATION E <br />5 20 <br />MIT/SERV <br />r 4 <br />ICES <br />Application is hereby made to TaMiliinWiii\r(tPEIS3 permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin ;',ounty Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Cross Street City <br />43%205 1,t::isltors et_,D__D <br />140-q ' —Oa), 110, 5 160 `1•11 <br />PROPE _ IN4j, fr <br />Owner C-r a ;Address City .4_- 2$hone# 02)2 3'7 / V <br />C-57 Contractor i4 006101, k brress PI) 412' City Zip °N167iLic#7Th°71hone# 37 Ce tAtze, <br />Consultant / Sub Cntr Address Ar7 s-4-4-sm Mcitrslic/i1124514,# phone# 2 0q (-1610.O6 / 6 <br />WELL <br />g- <br />GIS Coordinates: X , Township Range Section <br />WORK TO BE PERFORMED: <br />a NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />a SOIL BORING # <br />II WELL # <br />fl *Other <br />COMMENTS: rAf f>i-do-, rlYuk <br />icESTRUCTION (choose typegy4 <br />E. DIAMETER <br />PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />—C <br />cA <br /> <br />CONSTRUCTION SPECIFICFIONS <br />DIA. OF BOREHOLEek tiltMULTIPLE CASINGS ULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS /VA- TYPE CF CASING: a STEEL a PVC p OTHER: <br />DEPTH OF GROUT SEAL 4/5- Fed-TREMIE TYPE TO BE USED: jje(UGERS 0 HOSE <br />T)GROUT SEAL PUMPED: ficfes 11 No NOT : MAXIMUM FREE-FALL DEPTH IS 30') <br />CONDUCTOR CASING PROPOSED <br />COMM.FNTS: k/tflf — :Dr/ e294.4— /7) -- go:32— <br />,4-4,4AT ipitts5wa_01itij 4 av-eA4:1AAJ26-4-- 7 M65 <br />NOTE: OFFSTh BORINGS REQUIRE ACCESS AGREEMENT CR 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x 14401/4-14-4— Title/Company 4e=i74:571-- k1- <br />Print Name Name bliKe Date <br />DEPARTMENT USE ONLY <br />pc( <br />inal Inspection By <br />Date <br />703.z. Wec&a0-0 201 <br />ACCOUNTING ONLY: <br />_ <br />AID# FAC4 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE pERMIT / VSE ICE II ,R!T# INVOICE <br />SR#na 3? CF 1 ) 9S-0 0 — - _-5-4- N-k-- : <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />Encroachment ctor <br /> <br />Loc;ationP-I3 <br />TYPE OF WELL <br />,1IONITORING <br />a EXTRACTION <br />1:1 VAPOR <br />AIR SPARGE/ OZONE <br />U SOIL BORING <br />OTHER: <br />INSTALLATION TYPE <br />..‘HOLLOW STEM <br />a AIR HAMMER/DRIVEN <br />a MUD ROTARY <br />fl <br /> U HAND AUGER GROUT SPECIFICATIONS APP-440 <br />PUSH POINT (GP or CP <br />U OTHER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or U STOVE PIPE <br />(if YES, list specifirayons in comment section) <br />X65 <br />SITE MAP MAP IN UNIT IV FILE, rSS: <br />WORK PLAN DATED: <br /> <br />Application Accepted By <br />Grout Inspection By Date <br />Destruction Inspection By <br />COMMENTS! CONDMONS• CM—r- 10) Lee <br />Date Issued 4.( <br />Date <br />Area ly7 <br />EHD 29-02-001 <br />9/30/2002