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Mar-20-02 02 :47P VIRC -X, INC. 510 bS 7679 P.04 <br /> N FLDU <br /> FIFTH rr�+1jc v� <br /> 03/''0/200'_' 13:04 '_'0946,�/3 FIFT F �../ -- <br /> d-5f r:)1 1 r 0.'. rJ7=JO Lc'7gOP.»J� <br /> a <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> UNIT IV <br /> SAN JOAQUIN COUNTY <br /> 02 ENVIRONMENTAL HEALTH DEPARTMENT(EHD) <br /> 304 E.Weber,Third Floor, Stockton, CA, 95202 <br /> po% 468-3449 <br /> NON Jt[iUNbABF.E PERMIT E2Sttgg�j ykAg t'ROM PATE ISSUCO <br /> ppll�an is hereby mbe in San SeaQuin County for a pKmtit to oonetKid and/or install the work t�eses�bed. This H 81th D PS-b' ht' in tbmDlwhcc with San <br /> jequin County DevelopmoMT">tie,Ctvaptnr 9-1115.3 and the Standards of San leaquin County Err-6ronmental Hee{fh C10pa Assessors <br /> 4c ift�2Z L1xV i tt GZ I� G+o�street E7 t „4 C-'+' City-1)L"�c, Parte <br /> FELL Lncntlon t <br /> •57 Conttacer <br /> Z <br /> E1rcey7 oL93 <br /> 7r�o59J27 —"6'- L910 � 0 COQ� PhOnT <br /> ROPERTf Ownr 4nG. Addess# � `tyGXN <br /> d a rn � CiYS 'Zp [77 Lie <br /> 1IO Peet <br /> Y �' Addres <br /> 510-5G 8 7676 <br /> o„6ukant I Sub Contractor <br /> �,2 address I D r ^i ccs u ty .oma <br /> Towh3h1P f2ans}e sBator_ — <br /> ct5 Coardlnatcs:7t Y- <br /> ag TD BE PIEI t t~ bE8TRL;m0m(Choose type nelow) <br /> NEW WELL 1 BORING(CPT.aEOPROBE,HYDRDPUNCH,HANG AUGER, Ptt'1 ❑OVER-13DRE <br /> Q SOIL BORING a` - U PRESSURE GROUT <br /> `�''�''t'#�N 5 GrwlBpeciflcat}ons: <br /> other: <br /> :OMMENTS: <br /> YP F LL <br /> It+s'ra�t aTf9►+_� CON jEUMMM SPECIFtcaTIDNS <br /> O 2 u <br /> DIA_OF BOREHOLE MULTIPLE CASINGS?l7 YEg Q NO WELL CASING Ili <br /> �IONITpFFNG1011.QW STEM STEEL D OTHER' <br /> i EXTRACTION 13 AIR HAMMER�RNEfI CASING THICKNESS 0 ��' Of t:I►SING: O <br /> l VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �L —TREMIE TYPE TO DE USED: 'I)AUGS" �tCSE <br /> 1 AIR SPARGE a PUSH POINT' GROUT SEAL PUMPED; 13Yes 4eNo (NOTE: MAX)MUM FREE-FALL DEPTH 15 o') <br /> p `(� 2 -G PYL ZI Gt a <br /> 1 SOIL BORING o HAND AUGER GROUT SPEGFICJITTONS, ^`�^"'�`' BOLTED TpgFPtC Box• or Q sroVE PIPE <br /> 1 OTHER' a OT4ER_ _ - APPf70X_BORING DEPTH <br /> ,,CONDUCTOR CASING PROPOSE02 — Of'rM kr-1 SvedficatkHW I'lorc)_ <br /> COMMENTS' W ►rXIYY 6)- 100 :5H1-r-4 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION5, <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> :ounty Ordinances,Rules and Regulations,and all applicabIg California State lLaws. J I <br /> Tk1BICOmpanY_ I� <br /> iignM x <br /> 'riniNamc DEPARTMENT USE ONLY <br /> S <br /> ATE MAP IN UNIT IV FILE,ADDRESS' <br /> AlORK PLAN DATED: <br /> Da1IsaUed �/ <br /> �jPtiraUon pcCePtcd BY <br /> r p Date cf (> i F(rTa}tnsveeson By Oeste <br /> 3rout inspection 13 <br /> ]eevvotion Inspector+By Date <br /> �OMMEIYM r CONDTTIDNS- <br /> ACCOUNTING ONLY: AIDS car, <br /> PE CODES FEE INFO ANDLINT REMI'"Eb CHECKS REC C BY DATE PERMIT I SERVICE Me <br /> OUEST t INVOICE <br /> V3 Z D y $ ZZ <br /> G-57 WCC WAIVES? C-57 Letter of Authorization to sign permit—Encroachment doh_ 1/Z5102 <br /> 03/05/02 TUE 09:89 1TX/RX NO 54041 IA003 <br />