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H. I"LUUR PAGE 0_ <br /> �1/ELL ERMIT APPLICATION FORM <br /> tJ <br /> SITE <br /> SAN JOA©UIN COUNTY MITIGATION <br /> AUG 1 8 2004 ENVIRONMENTAL HEALTH DEPARTM5NT (EHID) UNIT IV <br /> ENV1RG('SME�T Egj404 E.Water, Third Floor, Stockton, CA,, 95202 <br /> PfhiJilTlS.•R�}CES 1209)458-3"9 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IG51JE0 <br /> AppllC2don is hereby mads to San Joaquin County for a perrnii 1construe,anVor rsa!f the 77t ciescribecL This appicatlon is made in comp!i,nce with San <br /> Jozquln County Development Title,Chapter 9.1 ti8.3 and the Standards of San Joaquin Caunty Envimrimantal Health Daparnent, <br /> Assessor's <br /> WELL Location 01.1 yr,lacte'ord SON&* Cross Stwi California City Lodi ZpJ96240 Parcelp�3 ,j <br /> P3 pepry Owner Le ,nwen Aderssa P,O aoK 203 City Lcl Vford Zip9S237.Pllotiel 209-7 7• !27 <br /> C-57 Cor:actor Facln EnAronmenisl Address 329$had's Race City VallavS rInC5ZIp a625t".Lim B83EBSPhcnc#2C9-T72 2570 <br /> Consultant f Sub Contractor Ground Zero Analysis.!nc. Address 1714 Mair SWO oty E:;ra cnn Ucc# Phonei 209-ve 8883 <br /> G;S Coorclinates:X_ 121°16. 6'W Y 38°08.3034'N ,Township 23 Ranaa- 9E Secton _2_3 <br /> VMBM 70 OF PF_IRFQR10EjZ <br /> iXI NEW WELL!ECRING(CRTOPROL'8, D:ZQPtJNGH,HAND-AUGER,CTHERI 0 DESTRUCT;ON(cheese tyes burr.) <br /> p6 # 8;1-ge _ a OVER-SORE i <br /> I I WELL# .d PRESSURE GRCUT <br /> 'Other. Ncai ceM-nVb9nt9nItr grout + <br /> COMMENTS:. <br /> TYPE OF WELL INSTALLATION TYPE COiJSTRUCTION SPECIFICATIONS <br /> 11 MONITORING a HOLi.OW STEM. CIA.OF 80RE-iCLE z MULTIPLE CASINGS?C Yi S [XI N7 W9LL CASINO-DIA: NA <br /> ­ <br /> a EXTRACTION [I AIR HA 1MEPJDR€VEN CASING TKCKNESSNA TYPE OF CASING: d STEEL 0 PVC GOTHER; = M i <br /> 0 VAPOR II MUM ROTARY CEPTH OF G:RtCL'T SEAL 10-20R TRERE TYPE TO BE USED: Q AUGERS Ix]HOSEF IPF I <br /> II AIR SPARGE Pq PUSt.POINT GROUT SEAT.PUMPED: n Yes pt]No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> {x1 SOIL BORING p BANG AUGER GRQUT SPECiFit.0.TION3:__tdeat cemrntrognicnite 4raut _ <br /> []OTHER; OTHER APPROX,BORING D_PTE410-20 ft BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTCA CASING PROFCSED? t if YES,Ilst Spe&!C31i0n&Iters): � <br /> ,COMMENTS: <br /> NOTE, OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances,Stiles aryl}R gtiI tions,and all applicable California State Lavm <br /> glared x I� Titlorc;arnpany CA F.e It�ed[tieo 7 5 Gras,rtt�Zerc Anai sis.Inc. <br /> A I <br /> Pr£rtt Name JClin P.Lane Date V <br /> DEPARTMENT USE ONL <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORT(PLAN DATED: <br /> Applics5on Aoeapi¢d By /' ` Date Issued_ d arca Ly <br /> I <br /> Grout Insaavicn Sy Data Final lnapeaFcn By Date <br /> Dastrjllon InspWIor By - pate II <br /> COMMENTS!CONDI7TONS: - <br /> i 1 <br /> ACCCtJ MNG ONLY: A10-4 <br /> FAGaZ <br /> Pe CODES FEE:NFD A�_7�:7 <br /> TTED C14ECK I RECD BY DATE I PERMIT I SERVICE REQUEST N INVOICE <br /> a-x G I I 3-1Z 3 127 q z <br /> C-57_ WC_-W,AN€R— C-57 Letter of Aut•harizatien to sign permit Encroachment dac____ 1/25/02 <br /> it <br /> I <br /> I <br />