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07/19/2002 08:18 2094683433 ruin r��ut <br /> WEI-L PERMIT APPLICATION FuRM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY uffr( <br /> l, <br /> wp <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) �_iL, ,�, � <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 NOV 1 3 2002 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDFI'J /I ' I'y <br /> JT H TH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made� ptr+' <br /> Joaquin County DevelopmentTftle,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. JI ttiiVV� <br /> r '� Assessors <br /> WELL Location 3`;C"+ I�)k Aeylasl,� l cr.+; TCross Street City J^_r��_� Zip�5?0—�Parcel# I�\�'` <br /> PROPERTY Owner oPCicKCo�J Address -'-201 W, �Vt�ii's�J=''T='nJ City :^ck�ry Zip Cf- Phone#L2'C'i 1G`l'l <br /> C-57 ContractoriE17- Ca '5 CVN,i;M Address 31t i L)1_M � a k�IE City V Uc#tiL,('110 Phone# T-n-1E�o <br /> Consultant/Sub Contractor U L c Fio�C<h., Address�� t.� +- a�City ' un: Lic# Phon SIo $�t3-3EW <br /> GIS Coordlnates:X ,Y .Township Range Section— <br /> WORK TO BE PERFORMED <br /> EW WELLORI'G ,GEOPROBE,HYDP,OPUNCH,HAND-AUGER.OTHER") Q DESTRUCTION(chaose type below) <br /> 1]SOIL BORING# U OVER-BORE <br /> 0 WELL# p PRESSURE GROUT <br /> 'Other. Gf"�— Grout Specificatlons: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITOPING 0 HOLLOW STEM DIA.OF BOREHOLE1S i_MULTIPLE CASINGS?0 YES &NO WELLCASING DIA <br /> q EXTPACTION n AIR HAMMER/DRIVEN CASING THICKNESS &'7;TYPE OF CASING: o STEEL o PVC (]OTHER: <br /> Il VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ,V HOSE <br /> n AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: �Ye' gNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> I)'bIL PORING rl HAND AUGER GROUT SPECIFICATIONS: <br /> n OTHER; KTHcR �'�"� APPROX.BORING DEPTH h2Zj 0 BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? VI�P (if YES,list specifications here): <br /> *COMMENTS: �l�,PStl.^FoCE ]►�Li :�' �` <br /> NOTF_: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> C:All_t„THP I INIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Orriinan As, uses anci Regulations, and all applicable California State Laws. <br /> r <br /> Signed x _ Tide/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> ApplicationAcceplec!By, , Date Issued4ty <br /> '� Are U_�.✓tZt� <br /> Grout Inspection Sy Date 7-607— Final InspecDate <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# Fermi <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REVO BY I DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 1a / 57 - ��i, L 1I 0iSRlt 00319/0 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doe_ 1/25/02 <br />