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, Township Range <br />ENVIRONMENTAL litalli <br />135 mm05 304 E. Weber, Third Floor, Stockton, CA., 9520 03 FEB 33 PMEItegiFONMENTAL HEALTH DIVISION (PHS-EHD) <br />POR N JOAQUIN COUNTY PUBLIC HEALTH SERVICES 'Mrr SWICE <br />VVELL PERMIT APPINFON FORM <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS <br />,pplication is hereby made to San Joaquin County for a perrnit 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 Public Health Services, Environmental Health Division. Assessor's <br />'NELL Location 2Z i ( is.1 . \UI LO) wil.. Cross Street ORW13010 City — Zip_q_i_Parcel# <br /> <br />ePY1,1E_ City Zip Phone# <br />PROPERTY Ownera ?fi. TV t.._,LA41).e..,10.4.2dairess <br />city giW-5 <br />C-57 Contractor AEp c.., r; a ,L.Laa lktd r e s s 6--6 <br />E v.46, Lo D Ligia_75:.a_Phone# zor6,6---rs6 II,D <br /> <br />'R Address 1239S VJ <br />Section <br />1 IP Ili 1> <br />PRESSURE GRO T <br />Grout Specifications• oLL. , <br />(VTUCW) DESTRUCTION (choose type below) <br />B OVER-BORE <br />PE CODES FEE INFO <br />*Other_ <br />COMMENTS: <br />OLLOVV STEM DIA. OF BOREHOLE MULTIPLE MULTIPLE CASINGS? il‹-E-S 0 NO WELL CASING DIA: 4"4111 LATION TYPE <br />0 AIR HAMMER/DRIVEN CASING THICKNESS 5N-i 'q D TYPE OF CASING: I] STEEL ifi,FIC El OTHER: <br />P MUD ROTARY DEPTH OF GROUT SEAL_Ca. TREMIE TYPE TO BE USED: 0 AUGERS egOSE <br />GROUT SEAL PUMPED: tr<es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />— <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH 106 TO 13 f7 OLTED TRAFFIC BOX or U STOVE PIPE <br />*COMMENTS: t 5— --FL) t a 01-0 •-L 1, IP <br />County Ord' nces, e nd R ulations, and all applicable California State Laws. <br />Title/Company <br />Signed x <br />ME-COP-T <br />MITIGATION <br />UNIT IV <br />OA/ <br />41fal diP <br />IP <br />Consultant / Sub Contractor <br />GIS Coordinates: X , Y <br />WORK TO BE PERFORMED: <br />erNEW WELL / BORING ( CPT, OPROBE, HYDP(1„ m I r"j <br />,iOIL BORING # <br />arkniFI L • <br /> <br />TYP OF WELL INST <br />64 ONITORING <br />0 EXTRACTION <br />[I VAPOR <br /> <br />AIR SPARGE fl PUSH POINT <br /> <br />B SOIL BORING HAND AUGER <br />B OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />OTHER PROPOSED? ( if YES, list specifications here): <br />COND1JCTOR CASING <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL R <br />this application and that the work will be done in accordance with San Joaquin <br />I hereby certify that I nave prepared <br />A P A TTQC rivo ez.4:C2LA ) DorTF-_c) tp4 oz- <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHME T PERMITS. <br />EQUIRED INSPECTIONS. <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDR <br />WORK PLAN DATED: / /4/ d <br />DEPARTMENT USE ONLY <br />S: 2- ( P- GoP <br />COMMENTS! CONDITIONS: <br />ACCOUNTING ONLY: <br />-WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />INVOICE <br />9/27/0C <br />Date Issued <br />Final Inspection By <br />Area <br />Date <br />C-57 WC <br />AA.AA-4 <br />ea t)r <br />AID# <br />AMOUNT REMITTED CHECK # REC'D BY DATE <br />3-5-03 <br />PERMIT! SERVICE REQUEST # <br />,o5h <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date <br />Date