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WELD=RMIT A'PPUCATION F '1A <br /> SAN JOAQUIN COUNTYIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (E �EUNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95M 0 1 2004 <br /> (209) 468-3449 ENVIRONMEFFNT HEALTH V t' <br /> R­FR-0M DATE <br /> Application is hereby made to San Joaquin County foNON-REr permit <br /> to construct E PERMIT and/or installPIRES I the wo k desc'ibed.PWjjapT�'MVi3'g'dde in compliance with San <br /> Joaquin County Developmept Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> 4; / I / I / Assessors <br /> WELL Locatior� 11 :ncn� :"r4r"-C-4 Cross Street r'1 1 '4 � City S-1�- on Zip 20,5 Parcel# N A <br /> PROPERTY / t� / <br /> Owner y-' ,4 7 S4"� n Addressy2S. IV. L I bftrj& City5 ac. -t -,, Zip 3762.Phone# 2Z < -83-19 <br /> C-57 Contractor�nm'-�LS:d to Address95o Wf« Rot City Mgr4.,Act Zip yss?Lice s,564jdPhone#4 Z5-.;a- <br /> Consultant/Sub Cntr <br /> 5-.;a-Consultant/SubCntr Address2.�4o I�Lrkr.ys 514• City$4bA-xo. Lic#V< 6Q7� Phone#!C_4 -`/850 <br /> GIs Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> `,KNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER.) 0 DESTRUCTION (choose type below) <br /> ]]SOIL BORING# 3%-Z2- C Ij lZwJC,6ti []OVER-BORE. DIAMETER <br /> []WELL# __ 0 PRESSURE GROUT <br /> []•Other t /A4F� GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING []HOLLOW STEM DIA.OF BOREHOLE []MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS A//A TYPE OF CASING: 0 STEEL []PVC []OTHER <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL I Se 7 - TREMIE TYPE TO BE USED: . []AUGERS JrHOSE <br /> U AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )KYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> >KSOIL BORING []HAND AUGER GROUT SPECIFICATIONS T .,4(g-,Ol (d.rtic.n� /'77 <br /> []OTHER: fl OTHER APPROX.BORING DEPTH /ZSc []BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /V .4 (H YES,list specifications in comment section) <br /> COMMENTS: CFsT .s rin SQ—m 4LrL .SZi- 2 <br /> NOTE: OFFSITE 136'RINGS REQUIRE ACC SS 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 Ordinances, Rules <br /> saand <br /> /Regulations, and all applicable California State Laws. / <br /> Signed xC. rnk"o., <br /> Qno _TiUe/CanpanySen;orS-fo'�-F Ga.�.�ec�3-f — <br /> Print Name G - l4T+ M ' n•I Date S(-L�5 (C-'� <br /> �DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: —C:) <br /> Date Issued 7- Area ` 6 a C/ <br /> Application Accepted By <br /> Grout Inspection By Date I Final Inspection BIOO. rOnpate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> mal ra$ � � 1Q65 6 I SR# 6b3P 22 <br /> C-57_ WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit_Encroochhmeent doc_ 9/30/02 <br /> `� � 9F d� <br />