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05/05/2003 14:49 2094693e-I FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> MITIG <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL dFAooH T , <br /> 304 E.Weber, Th Stcton CA-, <br /> (209) 468-3449 <br /> MAY 0 8 <br /> NON-REFUNDABLE PERMIT EXPIRES l YEAR FRO DATE ISSUED <br /> scribed. This cation is <br /> l in <br /> vie vvul­ <br /> Appli <br /> cation is hereby made to San Joaquin County for a peel Standards of San Joaquin County Env ronmental H alltthllDepartme G�Assessor's <br /> ani Wtth San <br /> Joaquin County Development Title,Chapter 9-1 1 3 and e Z parcel# 16 - <br /> Nf R D t21 Y Cross Street City SbC►cT� Ck Z1P _.�.-- <br /> wSLL Locatlon SOS v C p phone# 94 3 -5 C'2- <br /> Address ?9kl rf`y� nr;,rr r-.rKTor( Zip 95=� <br /> Ch <br /> PROPERTY Owner SERyI f q Lial#26S.SS Phoney 916 4 ?�O <br /> Address K tJ u CityRcr+ ����P r <br /> C-57 Contractor K p LIPhone# 51 g 9 O <br /> c r 'R PO2 � Address 5r'^ 1�11 Ct SwiF 22o City N — <br /> Cor+sultant JSub Contractor — Section <br /> Y Township Range <br /> GIS Coordinates: <br /> WORKTO BE PE FO MED: 1]DESTRUCTION(choose type below) <br /> Z'NFW WELLI BORING(CPT GEOPROBE,HYDROPUNCH. AND•AUGER OTHER•) 0 OVER-BORE <br /> []SOIL BORING# 6 PRESSURE GROUT <br /> pWELL# 2_ Grout specifications, <br /> ,other: <br /> COM_MENTS: <br /> TYPE_ OF F WELL INSTALLA7 ON TYPE CONSTRUCTION SPECIFICATIONS WELL CASING DIA: _'� <br /> ONITORING HOLLOW EM DIA.OF BOREHOLE8" MULTIPLE CASINGS?0 YES a NO <br /> AIR HAMMER/ORIVEN CASING THICKNESS— OF CASING: 0 STEEL $PVC [I OTHER <br /> ( EEXTRACTION D TREMIE TYPE TO BE USED: 113 AUGERS i HOSE <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> [{AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: )LYas 0 No (NOTE. MAXIMUM FREE-FALL.DEPTH IS 30'} <br /> S IL BORING t[HAN GER GROUT SPECIFICATIONS: <br /> n OTHER:���O OTHER APPROX.BORING DEPTH o P To p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? KU (If YES,list specifications here): <br /> •rntwtulENTs: IkOD� <br /> SUgs G <br /> NOTE: OFFSITE BORINGS REQUIRE <br /> ACCESS <br /> IN ADVOANCE FOROACALL R QUIRED INSPEPERMITS. <br /> C ONS. <br /> CALL THF UNIT IV INSPECTOR 48 WORKING HOURS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, les nd Regulations,and all applicable California State Laws. <br /> TitlelCompany <br /> Signed x 3 <br /> Date <br /> Print Name E)t ARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued Area—r! <br /> Application Accepted By Date` <br /> Date_ Final Inspection By <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# cd <br /> tPECODES FEE INFO AMOUNT REMRTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> S # <br /> c-57 Wc!-waIVER_ <br /> G-57 Letter of Authorization to.Sign permit Encroachment doC 1/25/ <br />