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03/06/03 12:38pm P. 00S <br /> LPjiJ <br /> WEPERMIT APPLICATION FIRM SITE <br /> J /Q1UI SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, GA., 95202 <br /> (209) 468-3449 KIbINAL <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is herebymade to San Joaquin Countyfor a permit to construct and/or Install the wrk described. This application is made in compliance deh San <br /> Joaquin County Development Title,Chapter 9.1115.3 and the Standards ofSan Joaquin ountyEnvlronmental Health Department, <br /> /)J IC 1, n - //W Assessors /i) <br /> WELL Locatio r IV rl, Cross street L(JKC(' ily ZIP Pafcel# ww1 <br /> PROPERTY Ownc CITY OF Tom- Address , `6 CItyjV,8L_y 7Jp­j'�,& Phone��w <br /> �T v '.17'"3i a7�L t(oL�1� ta.s9i�►� c,51. 5219 } b, <br /> C-ST Contractor Ia�f_ II 'G /' Atltlress Z'-L Gil ZiLic# Phone#�e6)�3'1I(O <br /> Consultant Sub Cntr� C,VLL1jt; AddroseR•.Q *f3Y- 90Z. CItY >`+I C.I/tLidf Phoneil� 01)) �I nl„i1 <br /> GIS Coordinates:X Y ,Township Range Section <br /> woR(TO BE PERF22!nlz, <br /> 't13'NEW WELL BORING (CPT,CROPROBE,HYOROPUNCH, IVEW <br /> ESTRUCTION (choose type below) <br /> /N [V901-[V901-B v V OMR-BORE, DIAMETER <br /> VtELL# q PRESSUR&iOUT <br /> *Other ROUT SPECIFICAYIQJS <br /> COMMENTS: /4Lr- �tir^'GI �d�ri{,�'ey1 <br /> TYPE OF HELL IPS ALLATI0 TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA,OF BOREHOLE U MULTIPLE CASINGS p MULTI-LEVEL VZLL CASING DIA <br /> 0 EXTRACTION O AIR HAMMER/DRIVEN CASINGTHICKNESS TYPE OF CASING: O STEEL U PVC 0 OTHER: <br /> 0 VAPOR U MUD ROTARY DEPTH OF GROUT SEAL v TREMIE T'fPE TO BE USED: O AUGERS 0 HOSE <br /> VR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: U lks O No,(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> IL BORING U HAND AUGER GROUT SPECIFICATICNS GF+F/- D <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BCD( or O STO/E PIPE <br /> AA CONDUCTOR CASING PROPOSED (if YES,list speclications in comment section) <br /> COMMENTS: 06-r4 Cr QN L64y- 10c,*-J QAW 3/1W _ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby ceW <br /> ared this application and that the work will be done in accordance with San Joaquin <br /> County OrdRegulations, and all applicable California State Laws. <br /> Signed Title/Company /nd/'4cV( <br /> Print Name '('P"'LV� Data <br /> P RDEP�A�RT�M,E/NT�USE ONN/LY <br /> SITE MAP IN UNIT IV FILE,ADDRESS6 / "'YCN►C /vr _�P <br /> WORK PLAN DATED: "3—t-0') —� <br /> Application Accepted By Data Issued area <br /> Grout Inspection By Date Final Inspection B �a a Sr�riz <br />