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WELlr-Pt:R 1 i APPLIGA ION c"ekd <br /> HEMMED ED UNLIT IV <br /> TIflN <br /> SAN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> SEP 10 ZM 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> - ENVIRONMENT HEALTH (209) 468-3449 <br /> pF� MIT/SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> application is ereb made to San Joaquin County for a pemtit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1915.3 and the Standards of San Joaquin County Environmental Health DDeepaartme/nt r <br /> AssessWELL Location--ls West �n ��(iv x� Cross Street .Y'(�S _City� T-�p P�oi <br /> PROPERTY Owner eY-QUNQ.�Address Q ll ((lam City n �a.fvlcll T�p_RYS '.Phone#�,�f1S�7N�—90x,,83 <br /> C-57 Contractor (n s--a DC,��IIWAddress <br /> Consultant/Sub Cntr )� (5) P- Address Za SV�� IQc`�cttyStix u-r• � Phcne#(S�A�lylo7-�sab <br /> ' GIS Coordinates:X Y Township _ Range Sedlon <br /> WORK TO BE PERFORMED: <br /> — 3 NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER? STRUCTos1C�Pd( loe type below) <br /> a SOIL BORING# /,DE <br /> O BORE <br /> EI WELL# y.,� (�1 UR <br /> GR <br /> 'cher; Grout Specifications_ _ <br /> COMMENTS <br /> VWF <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITOftlNGHOLLOW STEM DIA OF BOREHOLE S,a�„MULTIPLE CASINGS?a MULTI-LEVEL? Ia WEI 1 CASING DIA:_ <br /> — p EXTRACTION iI AIR HAMMERMRIVEN CASING THICKNESS A)A TYPE OF CASING: 0 STEEL B PVC O OT'HE2 <br /> Q VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL 1-?)�TRIED VE TYPE TO BE USED: AUGERS a HOSE <br /> a AIR SPARGE/Ozone o PUSH POINT GROUT SEAL PUMP©: o Yes o No (NOTE: MAXIMUM FREE- ALL DEPTH IS 30') <br /> — 17 SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: <br /> kOTHER:COJf I '.Zt A. C;OTHER APPROX.BORING DEPTH Lg� 0 BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPCSED? (if YES,fist spealications here): <br /> _ 'COMMS°ITS: - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THEUNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSFECTIONS. <br /> ! 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 Caiifomia State Laws. <br /> Signed x yam,, de/CanpanY <br /> Print NameT� ."1 n 1 1 Date — <br /> DEPARTMENT USE ONLY <br /> Q <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: C7 <br /> Application Accepted By Date Issued ��/�/ Area <br /> Grout Inspection By Date " Fnal Inspection BY Date <br /> Destructicn Inspection By Date - <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE 'PERMIT/SERVICE REQUEST# INVOICE <br /> 3�iz. Ica 19 3 -I C7 .5220 <br /> C-57 WC -VI%AIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ 8/29/02 <br />