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, <br />ENVIRONMEN - <br />PERMIT/SER <br />RECEir <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />JAN 30 Z002 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />nRIG1N <br />WELL *FRAIIIT APPLICATION Ft. „nil <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />TYPE OF WELL <br />NitMONITORING <br />a EXTRACTION <br />a VAPOR <br />- a AIR SPARGE <br />SOIL BORING <br />El OTHER: <br />INSTALLATION TYPE <br />A-HOLLOW STEM <br />AIR HAMMER/DRIVEN <br />MUD ROTARY <br />a PUSH POINT <br />U HAND AUGER <br />fl OTHER <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 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, Environmentai Health Division. <br />Assessor's <br />WELL Location 2,-i•;1) i,,,..„,,,- i..:7,„C) Cross Street S. :/.%' iajtirill6-ccity (', -66.6...Z.0/ Zip Parcel# / 7 ei -te -06 '3 <br />d-3 ' , <br />PROPERTY Owner Vik.14.1-0 (i/tkcjeuCii,-.J Address if Ct.k.'"1 epi1,04. 44 . City Ii. A.,.iii.Afkii.,i Opt.--S,; -A6 0 Phone# t) ../1-( — 4 1 3.5-- <br />C -57 Contractor YirraiaL 'Pe-ILl..1 pi if Address SI.;.6' ..e.,, t017-7- itiii... City 514/164 ZIP 1742t• !jolt C/2 07 Phone# .(//L)67 - .s-s ,3 - <br />Consultant / Sub Contractor ADI' 1.-r f ztAli,/ e.:A/rkfreA/74/-Address 1 / Kt SiMiii (24) City 57461/47;,1/4 / Lic# 4S.,- 27 Phone# 44 <br />GIS Coordinates: X , Y , Township Range <br />r4-T0,43 PERFORMED: <br />W,Ekt / BORING ( CPT, GECPROBE, HYDROPUNCH, HAND-AUGER, OTHER') a DESTRUCTION (choose type below) 9.._) <br />Et SOIL BORING # a OVER-BORE 041 <br />WELL # /1.1 LA.., - '...›- a PRESSURE GROUT <br />\..) <br />*Other_ Grout Specifications: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? p YES tOIC WELL CASING DIA: 2 <br />CASING THICKNESS `IC TYPE OF CASING: STEEL )(PVC a OTHER: <br />DEPTH OF GROUT SEAL 5 TREMIE TYPE TO BE USED: OUGERS fl HOSE <br />GROUT SEAL PUMPED: Nres a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <fericilfsJo 711-17 71 <br />APPROX. BORING DEPTH S' C.; .eg-th OLTED TRAFFIC 3CX or U STOVE FIFE <br />( if YES, list spedfications here): <br />'COMMENTS: <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 have prepared this application and that the work will be done in accordance with San Joaquin <br />County Qrd4 ances,Rulean Regulations, and all applicable California State Laws. <br />Signed x Title/Com PanY )/4u 47Eb <br />k-Pf1t,t <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br /> Date Issued al/?' 2- Area <br />Application Accepted By <br />Final Inspection By Date <br />LA./11111VMM* 0 / <br />FAC-# "(2i; 7W - ACCOUNTING ONLY: AID#45Ni <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PERMIT 1 SERVICE REQUEST # INVOICE <br />-,-!- sR# 2 c(79 <br />, n in-7 Inn <br />Section <br />04c <br /> <br />CONDUCTOR CASING PROPOSED? <br />1,1/1.6:- Aft /-6.‘:244 L-tik'71 <br /> <br />Print Name Date <br />DEPARTMENT USE ONLY <br />‘Oeca..).-7 <br />Grout Inspection By Date <br />Destruction Inspection By Date <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit ncroac men oc <br />