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ATTU, kiKE_ tbFbizo A- <br />;- <br />kj 6 4gELPERMIT APPLICATION FORM <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) RECTi f-r1 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 AUG 0 7 2002 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app NiclEOPitiliVikici3V6001.0 with San <br />Joaquin County Development Title, Chapter 9-1115.a and the Standards of San Joaquin County Public Health Services, ElifIVRVIVErvision. <br />WELL Location .22 I ( 6.3 Wi L5N3 WAL Cross Street W6)01) City STDC..a)AA Zip C/6245- Parcel# 117360.2 <br />1%. <br />SITE <br />MITIGATION <br />Date <br />Date <br />957_, Elmo& Ci ty WAC-TiNIF.72g4953Lict 6071-ionP19 <br />Consultant/Sub Contractor Foal-kit <br />PROPERTY Owner COOL3 MOtalrriZ0d-rnelress Sig /1-4 E- City Zip <br />C-57 Contractor LY4Address <br />Address laq3 PAO Pj tetisz Phone#C&I)568- ygey <br />W9RK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCVAND-AUGER, OTHER*) <br />fl <br />WELL # le 41 S -110 14°1 1) <br />SOIL BORING # iqw <br />Grout Spe <br />LI DESTRUCTION (choose type below) <br />[I OVER-BORE <br />I] PRESSURE GROUT <br />cifications: i_A„) I to <br />*Other: <br />C3MMENTS: <br />If OF WELL INS ALLATION TYPE <br /> <br />MONITORING OLLOW STEM <br />p EXTRACTION 0 AIR HAMMER/DRIVEN <br />EIIVAPOR D MUD ROTARY <br />[I AIR SPARGE fl PUSH POINT <br /> <br />SOIL BORING 0 HAND AUGER <br />0 OTHER: U OTHER <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />e <br />that I have prepared this application and that the work will be done in accordance with San Joaquin <br />herby certify <br />FE <br />cF4 > 3 vie <br />DEPARTMENT USE ONLY <br /> Date <br />ol="// a4411 /(1/7 / <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: e • 2-- Are. as7Y/ <br />Date Issued --D <br />Date1:17-677_12-- Final Inspection By <br />GIS Coordinates: X , Y , Township Range Section <br />61?Dc <br />Afe'rEL ig ei/5'4e4gmv,_ <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE_ IL r,) MULTI E CASINGS? ES 0 NO W,LL CASING /s1( <br />CASING THICKNESS TYPE OF CASING: 0 STEEL,i4VC I] OTHER: <br />DcPTH OF GROUT SEAL 4D TREMIE TYPE TO BE USED: 0 AUGERS IKSE <br />GROUT SEAL PUMPED: U Yes U No (NOTE: AXIMUM FREE-FALL DEPTH IS 30') <br />*COMMENTS: PVC / 2/0 .t12.4& <br />i" lie. A C 1,40-et-e‘'S- 95" /treS <br />NOTE: OrFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH / DO <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />OLTED TRAFFIC BOX or STOVE PIPE <br />County Ordin ces, Re ations, and all applicable California State Laws. <br />11.-LAZ Title/Company <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: c71-I <br />I ACCOUNTING ONLY: <br /> AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # <br />1/471/111 <br />6.7"°2—SR# 030 grb 2 <br />C V -WAIVER C-57 Letter of Authorization to sign permit V Encroachment doc4/K-73172-77-66 <br />FAC:# <br />REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />350 <br />C-57