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I <br /> VSE PERMIT APPLI�ATIO'NMR11REC��C�]C ; <br /> SAN JOAQUIN C"OUNTYITIGATION <br /> APR 1 8 Z003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, "Stockton, CA., 95202 <br /> PFRMITISERVICES (209) 468-3449" <br /> NON-REFUNDABLE PERMIT EXPIRES 1YEAR 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 /> �r�r / Assessor <br /> WELL location r `` � Cross Street W " ! ( City 6t rim Zip j�Jy L ar 4 Parcel# <br /> PROPERTYOwnercl /uC�[,I �[-�-, Address2243 40. fQtfW Cit} J�"lri �ZiplvPhone# f <br /> C-57 Contractor"'VIAddress 177 &*UCi ,.S" ,� <br /> ty Zip JLtc#4DZZ7 Phone# `�67 1a� <br /> Consultant/Sub Cntr Q Q `- Address 6 37 (�v, �Citys rz �Lic# 7• Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO SE PERFO it <br /> "KNEW WELL.1 RIN P , OPR HYDR U CH; ND- GER,.OTHER") II DESTRUCTION"(choose type below) <br /> ORING#" p OVER-BORE <br /> 'WELL# [I PRESSURE GROUT <br /> *Other: :x Grout Specifications: <br /> COMMENTS i <br /> TYPE OF VVELL INSTALLATION TYPE 'CONSTRUCTION SPl`CIFICATIONS r" <br /> Ll MONITORING []HOLLOW STEM DIA.OF 80REHOLE MULTIPLE.CASINGS?[)MULTI-LEVEL?0 WELL CASING DIA: Al <br /> Q EXTRACTION 0 AIR HAMMER/DR€VEN `CASING THICKNESS d,4 TYPE OF CASING: [I STEEL U PVC U OTHER: <br /> [I VAPCR I]MUD ROTARY DEPTH OF GROUT SEALT-6TAL QWP REMIE TYPE TO BE USED: A6SERS 0 HOSE+:.' <br /> [I AIR SPARGE I Ozone*gPUSH POINT GROUT SEAL",PUMPED:Yes '0 No (MOTE: MAXIMUM FREE- ALL DEPTH IS 301) <br /> -)kS01L BORING [I HAND AUGER GROUT SPECIFICATIONS: d17(_f u-P --�7i�-�L _r&L <br /> a OTHER: '''I]OTHER APPROX.BORING DEPTH. � p BOLTED TRA FIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? JJO (if YES,list specifications here): <br /> *COMMENTS: <br /> y <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 haye prepared this application and that the work will be done in accordance with San Joaquin <br /> County O77= <br /> d Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> 44" <br /> SITE MAP IN UNIT IV FILE,ADDRESS; <br /> WORK PLAN DATED: L Q <br /> Application Accepted By _ Date Issued Area <br /> Grout Inspection By pate Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: L 0/p <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'DIBY DATE PERMIT!SERVICE'REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Leafier of Authorization to sign permit Encraachmerlt doc 8/29!02 <br />