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05/05/2003 14: 49 2094682 FIFTH FLOOR PAGE 02 <br /> ------------- <br /> WELL PERMIT APFLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL d FAloor}i Stockton CADEPARTMENT95202(EHD) <br /> 304 E.Weber,Third 4683449 <br /> MAY 0 8 21)03 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FRO DATE ISSUED I�Cation i5 made in comptfanoe with San <br /> County rtment <br /> Application is hereby made to San Joaquin County for a perrnit to construct and/or Install the work described. This app Assessor's <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin Coun Environmental Health Depa Parcel# ICI - 30'O t <br /> o .I VIE Cross Street — Clty IM22 T__-___aw`Z1p_ CA \ <br /> WELL Locatlon 1 c-rc.r hTor1 Zip 9 o Phoneii <br /> PROPERTY Owner E Address 509 nd WEUa AJe.STE IOCity_ c_I► �(ZO O <br /> Address?gR 3 — <br /> City RnckuN Tup9S Liolt3css�5CPhoneg j.� �13k <br /> C-57 Contractorl 221k ri(3r( Lich—�---Phone# 5 g 3 G <br /> consultant/Sub Contractor URC^�`^� cr!� <br /> Addn:ss City f]hKr/rnlD <br /> Y <br /> Range _Section <br /> GlS Coordinates: Township <br /> WORKTO HE PERFORMED_ 0 DESTRUCTION O(Odtoose type R-BOREbelow) <br /> jr NEW WELL!BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') <br /> 0 SOIL BORING# 0 PRESSURE GROUT <br /> R,WELL# Grout Specificatlons: <br /> 'Other: <br /> C.0MMENTS: <br /> �TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Z <br /> MONITORING B HOLLOW DIA.OF BOREHOLE_ $" MULTIPLE CASINGS?0 YES ff NO WELL CASING DIA: <br /> TYPE OF CASING: 0 STEEL V(PVC 13 OTHER: <br /> 0 VI <br /> EXTRACTION Q AIR HAMERIORI V EN CASING THICKNESS— TREMIE TYPE TO BE USED: GAUGERS WHOSE <br /> 0 VAPOR G MUD ROTARY DEPTH OF GROUT SEAL <br /> GROUT SEAL PUMPED: ') <br /> Yes G No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 <br /> 0 AIR SPARGE 0 PUSH POINT <br /> G SOIL BORING G HAND AUGER GROUT SPECIFICATIONS: I <br /> M <br /> APP <br /> OTHER ROX.BORING DEPTH ?0 1"1" e BOLTED TRAFFIC BOX or $STOVE PIPE <br /> II OTHER: G If YES,list specifications here): <br /> CONDUCTOR CASING PROPOSED? ►3f' <br /> 'GC;NIMENTS: <br /> �1Q 1 S Cl <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> GALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I haV prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, es an Re ulations,and all applicable California State Laws. <br /> Title/Company +0 1J R 0 Cis O <br /> Signed x — <br /> •1 � Date - <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued Area___. <br /> Application Accepted By Date Final Inspection By Date�� <br /> Grout Inspection By <br /> Destruction inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# Carlo <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY I DATE PERMIT!SERVICE REQUEST# INVOICE <br /> S � <br /> C-57 WCC WAIVER <br /> C-57 Letter of Authorization to Sign permit Encroachment doC 1/25/ <br />