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10/13/2003 13:59 714-F70-29$7 TRIHYDRO ANAYFTM PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) "8-3449 <br /> NON-REU IT EXPIR OM GATE I <br /> Application Is hereby mode to San Joaquin County for a pormit to construct and/or Install the work described. This spoieation is made in oomPflanoa with San <br /> Joaquin County��JDevelopmont Title,Chapter 0-1115.3 and the Standards of Sin Joaquin County Environmental Healthh Department. q i <br /> WELL Locatl.r 13 � D�4y ..._ _croas StraO WOK•�"� City T'O'G p `��`�� Parct l# 4ti,- <br /> PROPERTYQ <br /> �E���S Address ��'^C.. City —ZIP.Owner �� -- <br /> Phone# <br /> C-57 Contractor `1�,�� �fi Address City��a�^ 7JpfiLl ,�^ hone# I <br /> e e dxro N-0- <br /> r11�1Ll''lZ <br /> Consultant 15ub Cntr [ � rgaes JI A `* _G7fy Llc# Phone <br /> CIS Coordinates:XQ' Y �y� ,Township Range Sectlon <br /> WORK TO 9E PERE08MM <br /> p NEW WELL I BORING (CPT,GE O ROBE,HYDROPUN ,NAND-AUGM OTHER-) p DESTRUCTION (choose type below) <br /> SOIL BORING# 7. 1$ o� . ,rte ,jo B OVERBORE. QIAMETER <br /> p WELL# � r� J o PRESSURE GROUT <br /> (]`Other. GROUT SPECIFICATIONS <br /> COMMENT'S: <br /> TYPE OF WELL t YRE GON$T I T ONS <br /> 0 MONITORING p HOLLOW STEM DIA.OF BOREHOLEW_ a MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> la EXTRACTION a AIR HAMMERRtDRIVEN CASING THICKNESS_ TYPE OF CASING; Q STEEL�VC Q OTHER; <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL(3 — T. TREMIE=TYPE TO SE USED; d AUnIFRS NOSE <br /> a AIR SPARGEI OZONE X�USF1 POINT(GP or CPT)GROUT SEAL PUMP50: n YeaOt,N,o� (NOTE; MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING a HAND AUGER GROUT SPECIFICATIONS �,�' ^C�R t-- �P► C _ <br /> jl OTHER: 11 OTHER,,_, APPROX.BORING DEPTH C ]$' �BOLTED TRAFFIC 13OX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (If YES,list specificstions in comment secton) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT HERMITS. <br /> 43 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi a res, Rul s and Regulations,and all applicable California State Laws. T <br /> Signed x (�, C TltlelCompany y r i � 1 <br /> PrintName `" Date kb <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS; <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued l�?/l D Area <br /> Grout inspection By K,- Date 1 o zl Final Inspect on Byw bate _ <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: o Z - / L� ITT,27 7710e'f Jd cj <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REGID AY DATE PERMIT 13 ERVICE REQUEST#. INVOICE <br /> SR# <br /> C-57 WC_-WAIVER_ C-57 Letter of AUthgr-iZQtiQn to sign permit_ Encroachment dac____ ' 4/30/02 <br /> I <br /> f <br />