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Signed x <br />Application Accepted Accepted By <br />Grout Inspection By <br />AID# ACCOUNTING ONLY: <br />-71,6/11 <br />C V. -WAIVER <br />C O-57 /vv - 6.7-0 <br />DATE REC'D BY CHECK # AMOUNT REMITTED <br />no k KE_ ( p-u ;ay A- <br />(1)e72-1 FLA 21 14171_ PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <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 apphafiWiiiiieliciiiigWve with San <br />Joaquin County Development Title, Chapter 9-1115.a and the Standards of San Joaquin County Public Health Services, EBR3Mr)qtrItMItt-E-pivision. <br />AS-Sess/-7 <br />WELL Location 2.-2 Ll (13, wi L(57. \14f..\t,.A Cross Street M14/613-ab City Zip ct.526,5- Parcel# / 7.• .2(pU'L / <br />PROPERTY Owner C01001:1J- E- City Zip (11ga#41'C-74 II <br />4.0•Fr Cvzs) <br />C-57 Contractor6.3' flEC,C...2. Dili ILILYeAddress q OW D city hone - <br />Address laq3 CAD ixj, city4)1t--c.) Lic# etit2-2- Phone:4.0M 5428 <br />Consultant / Sub Contractor Fair 1-1 Doc, <br />GIS Coordinates: X , Y , Township Range Section <br />W9RK TO BE PERFORMED: <br />0'NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH4tHAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # .Q OVER-BORE <br />WELL # As( IP) c1i7 kJ `4-t1D I] PRESSURE GROUT <br />Grout Specifications: C 4-4/ir2tti ( /0 6EL- <br />C.DMMENTS: <br />TY OF WELL INS4ALLATION TYPE CONSTRUCTION SPECIFICATIONS _„-- <br />rYMONITORING Oi OLLOW STEM DIA. OF BOREHOLE_ 0.0,(MULTIKE CASINGS? 0 NO W LL CASING DIA:n I il <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL VC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY 131:)TH OF GROUT SEAL ---. 4 D ' TREMIE TYPE TO BE USED: fl AUGERS 14-11.6SE -- <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ()Yes 0 No (NOTE:71AXIMUM FREE-FALL DEPTH IS 30') ..... <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Cat..:( C ik"" i Gl. <br />C__ <br />D OTHER: 0 OTHER APPROX. BORING DEPTH i 00 1 OLTED TRAFFIC BOX or 0 STOVE PIPE E <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />. t <br />g' <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 Ordina9ces, Re ations, and all applicable California State Laws. <br />TfE, Title/Company 5/i/Ce.e.-176).?; <br />411 EAit i3viec,. <br />DEPARTMENT USE ONLY <br />*Other: <br />*COMMENTS: " 2,0 4e I <br />NOTE: OF/FSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />,5•:- /6-6 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: V.-if 4° • 0 <br /> Date Issued <br />Date Final Inspection By <br />Destruction Destruction Inspection By Date <br />COMMENTS / CONDITIONS: c:71-1( g "A/$7fr <br />A.. a0z 4 <br />Date /-6 -6 3 <br />_- - <br />PER SERVICE REOftt <br />C-57 Letter of Authorization to sign permit 17-- Encroachment doc <br />FAC# <br />FEE INFO PE CODES <br />Print Name <br />INVOICE <br />9/27/00 <br />OR Ib ItIA <br />SITE <br />MITIGATION <br />AUG 0 7 2002 <br />Date <br />9-e -