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Mar-20-02 02 :48P VIRC '11EX, INC. 51C '58 7679 P.05 <br /> F73/�©/2©f12 <br /> 13:04 2_0946, I I,-it- I rLuUm. <br /> N FIT"TH FLOUR `ve rNat rJ� <br /> 03/05x'2002 09:36 2094683433 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> � . SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> t 304 E. Weber,Third Ieftoar, Stockton,GA., <br /> 95202 <br /> (209) 458-3449 <br /> PDQ FROM OA ISSUED <br /> µpi1� U £p MIT EXP <br /> the irk dcsdit�d•Yom ,is madm in romplianee vdth San <br /> pPllr h�s hcrebY mnd.to Han Joaquin County tar a prn t to mncifuct 2nd/Or instil! <br /> sa4uin County t>t,t:topment Tiwa.Chapmr 9.11 is.3 and the 5teneards of San Joaquin``Gounty EnNronm®nt>i1 M=elVt Depa�trtsenLA <br /> JELL Location <br /> QY1 Tc - �� 0.v(r}t t Cross Strse!�YA►to(.CA+� C G— {i—c�G 'Z ZP Parxpt 6-172 0-C� <br /> 10224 v`a.w. ElftrC'nieJ1q 123. 2Q `�7_"I^� f bL, <br /> ROPERTY Owner <br /> I J lr ICvC� �h G, AdCrtSS,. C.. +t 4-ic Q _CitY�o�r�.r.r10 pP,yp��Phoc+e4 <br /> 2tto Ada-a.tot r ;ia :~lea z;p� � uml -5R2pno 51c-5bfs-767� <br /> -57 Contractor v 1� Address <br /> :onOultant I Sub Contractor I-T Co r P • A4drecs Ity("COeo <br /> t3 �t22 Phondk L125 28. 15 <br /> as Coordx <br /> Y ,ToumshlD Range Sectlnn <br /> YORK 7r`BE PEKFOR3+LE0= DESTRilCT10N(choose type below) <br /> NEyy WELL)GORING(CPT,GEOPRODE,HYDRCiPUNCH.HAND.AUGER.OTHER') 0 13 OVER-SORE <br /> SOIL BORING s 31S" (]PRESSURR GROUT <br /> othWELL O <br /> trr: Gtotn SpeclFlc�n3: . <br /> ;OMMENTS: <br /> ryp (L INSTAM AL(41i TYPE y-ON ()C_LON'�S,�SCtF)C/�71bNS �� <br /> MONITORING v�Fl0tl.OW STFM DIA.OF soPEHOt£_ v MULTIPLE CASINGS?Q YES ONO WELL CASING 01A:Z <br /> I EXTRACTION 0 AIR HAMMepioRIVEN CA$ir G THICKNESS 0.02- TYPE OF CASING: 0 ST13EL�VC 1:!AUGURS <br /> ]VAPOR p MUD RATARY DEPTH OF GROUT SEAI.� <br /> TREMIE TYPE T O 8E USED: O AUflERS OSE <br /> IAlit SPARGE O PUSH POINT GROUTSEAL PUMPED; QYca 0o,{NATE: MAx*AUM FREE-FALL Dr,E�PTH IS 30'} <br /> S7SOIL BORING a HAND AUGER GROUT SPECIFICATIONS:— ' <br /> 3 OTHER: n OT►iER APPROX.DORING DEPTH t "OLTED TRAFFIC BOX or I)STOVE PIPE <br /> CONOUCTQR CASING PROPOSED? (if YF3.%st spectfiCa6WS herr): <br /> "W <br /> 1 1 <br /> 'CpMMENTS: <br /> 40 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> -CALL THE UNIT IV INSPECTOR 46 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTK:)%S_ <br /> I hereby csrYity that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinarle ,Rulls and Regulations. <br /> and all applicable Callfornia State Laws. <br /> Signed - _ TitlNComPanY t <br /> Prin:"mo I `nn ,� SJ V tS) WV 1 l tZ� Patel U b <br /> PEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �_ _, <br /> WORK PLAN DATED: <br /> ppprcatlon A;tepted Dr�` ` Date Issued / Z D L a <br /> Gr=utlnspCts�^RY ^^ �' Date �i I. Final knsProdOn SY Date <br /> Dostructian Inapcdion B <br /> Detc I 1 <br /> cv>wtMENTS r CONDTTIOKS <br /> ACCOUNTIN G ONLY.- AID# c�rw <br /> PE CODeS FEE INFO AMOUNT REM3rif:D CHECKS REe'U D) DATE PERf✓rlff t si laVtCE RBCLUEST# 3NVOICE <br /> 30 <br /> C-57_ WCC WAIVER_ C-57 Letter-of Au0sonZatiort to sign prrmit_Encroachment doc` i/Z5/02 <br /> 03/03/02 TUE 09'39 [TX/RX NO 54041 Z D03 <br />