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10/08/2002 15: 27 707-58F ,900 VERTEX ENG PAGE 02/06 <br /> 10/07/2002 15;30 2094Gm3433 FIFTH FLOOR PAGE 05 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENTfEHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> N0N_1iki .IN0AQLE PERMIT EXPIRES YEaFt ROM DATE 1A9lIED <br /> Application Ie h®reby mage to San Joaquin Countyr ror a permit to Construct Llnd/ar Install the work dozcribed. Thiss applicstion is made in compliance with$a n <br /> Joaquin County 08v91opmant 744,Chapter 1 1115.3 and the Standards of San Joaouin County Environmental Health DepartnenL <br /> WELL Location sA 3QS Assessors <br /> Cross Stree( 0. CVL city p . Pmrpelft <br /> PROPERTY Owner f�G�V (r1 �t Address G r Zi <br /> t -57 Cnnhactor Addreso Ci �� 7 <br /> �i �r tY zlR LJc# Phone# 0 (7� <br /> Consukantf Sub ContraCtor�f wQ X �1aBrQs V C�4,u.ws�v _r CI ,+��1� L;(;# .T1 phone# 2`fes <br /> GIS Coordinates:X Y Towrtshl <br /> P Ren9e Section <br /> K TO B8 ]=RFORM$ <br /> EyV WELL!9DRING(CI T,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER*) a DESTRUCTION(Choose type below) <br /> U SOLI BORING# <br /> r r CS yUF.t Ll - Q OVER-60RE <br /> GroutSpeolft�at;ons: O'iaRESSURE GROUP <br /> MMEN7S: ` <br /> E 4F VWLL I S LLATIU � r rs CONSTRUCTION SPECIF�GJ1��pNS <br /> MONITORING a HOLLOW STEM DIA.OF BORFHOLE <br /> MU�fTIPLE CASIN(38Y[I YESXNA WELLGAS1YCi DIA <br /> Q EXTRACTION El AIR HAMMERIDRIVEN CASING TACKNIES$ 'L TYPE OF CASING: XSTpEL U PVC Q OTHEIy; <br /> C1 VAPOR Q MUD ROTARY DEPTH OF GROUT SEALMWQ0fTREMIE iYP>ff TO BE USED: XAUQEPRS ;HOSE <br /> ©AIR SPARGE `'USsH POINT GROUT SEAL PUMPED:)?Ss p No (NOTE,, MAY,[M M FRF_E.FALI,DEPTH IS 3w) <br /> 0 SOIL BORING 0 HAND AUGER GROUP SPECIFICATIONS:_ 1(2 a+L <br /> R X_ ate. <br /> Q OTHER; [I OTHER APPROBORING DEPTH SCS / 9 BOLTED FiCSdX <br /> "COMMENTS: or <br /> CONDUCTOR CASING PROPOSED? A (if YES,list ip2CitlCatfpn,here); <br /> ----- <br /> NOTE; OFFSITE EORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL_THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTICINS. <br /> I hereby certify hat I have pre r d this pplication and that the work will be done in accordance with San Joaquin <br /> County Or 'n ces, les n qu ati s and 11 a livable California wfoLaws. <br /> r i <br /> Signed x TitlelCampany <br /> Print Name 'N l c „_r' � <br /> p k TMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS! <br /> WORK PLAN DATED: <br /> Application Amepted;3y Oak Itsued <br /> Grout Inspection By Date Final Inspection By _,Date <br /> Destruction Inspection Dy Dam <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> f'1 CODES KEEINFO r1MOUNTREMITTED fELk <br /> PERMIT 1SERVICE REQUESTr/ INVOICE f <br /> I <br /> C-57 WC -WATVi'P,_ C-57 Letter of Authorization to sign permit„ Fncroachment doe 1/25/02 <br />