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10/08/2002 15:00 707-5s5-?900 VERTEX ENG PAGE 02/04 <br /> 10/07/2002 16:30 20946bb433 FIFTH FLOOR PGGE 05 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT.(EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON=REFUNDABLE PERMIT EXPIRI=S 1 YSAR FROM DATE ISM 110 <br /> Applluation Is hereby made to San Joaquin County for a permit to construct flndJor inatall the work descrlbed. Thia appllcatlon Is mode in compliance wilh Scrn <br /> Joaquin County DevAlopmdnt Title,Chapter 9-1115,$and the Standards of San Joaquin County Envlronniental Health Dr_p„,rtrnent. <br /> WELL Location-7-5_ 7 J��4 Cross Street �a i.AVS., City ' bC`-`"�__Zt�Parretla pr s <br /> PROPERTY Owner Address U 41 Ci J� ziW JPhona#ij 23-1.3/ 7 �� <br /> "7Contactor s�v64A-'�- Address cityZIP IJc# Phone © a - <br /> consultant r Sub ContractorJQ v� T <br /> ndress 0 �� ci .�a,- Lldt nor.., phoney r-21/010 <br /> GIS Qmrdinates;X _1y Townshlp Range Section <br /> — <br /> W K TO 8E PE FpRMEP: <br /> EW WELLf BORING(CPT,GEOPROSE,HYORCIbUNCH,HAND-AUGER,OTHER') Il DESTRUCTION(chooseVe below) <br /> q S011-BORING,# <br /> fw�/� v OVER-eok <br /> / � <br /> WELL 4 _ I�RESSURE GROUT <br /> -Oth Grout Spealfcmticrns; <br /> MMENTS: <br /> 31fPE pF WELL �t�fSJALLATIDN.TYP` CONSTF2UCTlt)N SPECIFIGATI4NS <br /> 'Am ONITORIN3 [j HOLLOW$TEM DtA.OF BOREHOLE MU TIPLE CASINGS?0 YESXNO WELL CASING DIA; � <br /> a EXTRACTION a AIR HAMMER/DRpJEN CA$JNG THICKNESS�1� <br /> mu <br /> CF CASING: XSTE EL 0 PVC 0 OTHER: <br /> U VAPOR n MUD ROTARY DEPTH OF GRQUT SEAL TREMIE TYPE TO BE USED: >(ALQERS Q HOSE <br /> Q AIR SPARGE U91-r P0(n1T GROUT S )le <br /> SEAL PUMPED: s a No (NOTr: r4AAJ IMYM FREE--F•r LL DEPT H IS 3Q') <br /> 0 SOtL ROBING n HAND AUGER GROUT SPECIFICATIONS; A42-a--(- <br /> 0 OTFIEft; 0 i3THEP._ _ APPRpX_PORING DEPTH__ / 0 BOLTEL7�RFFtC-LZX or 0 ST+D•�V P _ 't CL <br /> CONDUCTOR CASING PROPC56ED? n 0. .(If yes.list specifications hem);C I� _ M � W�S .,. ... ._,. <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESS OR ENCRQACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, <br /> hereby cert;fyEeS, <br /> lt I have pr® r d this pplicaticn and that the work will be done in accordance with San Joaquin <br /> County Or �10rn 9"i ns and It cable Gallforrtia to Laws. <br /> /!�� r P I <br /> Signed x T1tIeFComparry <br /> �J r _ <br /> Print Name l t r r, D'i <br /> D PARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted BY Date Issued �� 4 L Area f S_A0 <br /> Grout InapecE on$y �r Date, "�' `f t�r i Fina!Inspection By - y Daks -� <br /> D29truckri Inspection By Date <br /> COMMENTS!CONOrCIONS: <br /> ACCOUNTING ONLY: AId1� <br /> card <br /> PC CODES 15FE INFa AMOUNT REMITTED CHECK PREC'Q BY DATE PERMIT I SERVICE REQUEST 0 INVoIGE <br /> Sq- # '7,!� <br /> C-57 WC -WAIVED,,,,-,_, C-57 Letter of Authorization to sign perMi1�_Encroachment dc 1I25IO2 <br />