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FI;H 14 2000 4: 55PM Hf�.FSERJET 3200 <br /> 02/14/2002114l2002 10:18 289469 . 3 <br /> FIFTH FLOOR PAGE 02 p- 2 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA.,95202 <br /> (209)468-3449 <br /> NON EPE PERMIT EXPIRES 1 YEAR FR79MMi DATE ISSUED <br /> Application is hereby made to San Joaquin County or a permit to construct and/or install me work described. This opplirarron Is made In compliance with San <br /> Joaquin County Oevelopmentmde,Chapter 9.1115.3 and the su nderes of San Joaquin County Environmental--Health DepartmentAssessor's <br /> wELLLeutton 8�-� �'��x� "D Cross Street City ` Ip ParcdNt� "d� <br /> PROPERTY OwnsDTSSC_�SH+aQ Atltlres�'�EP1 r�Ad CIM-�ITI{ROP �iP PhOne# <br /> v,o it Address��k�EPa. CYyY�l1 ,Lipv4s_ylc#, Ib'�nenett 42S-313-58en <br /> C-57 Ccntractis C--• O-�en F�.ltWPr'! c�.vstx.. <br /> Consultant[Sub Conlractru�-kAU Ai11 Address -City SAC- <br /> LkN PhoneB 9l �-lo'1LiTZC?oa <br /> GIS coordinates:X <br /> Y ,Township Range Section <br /> WORK TO BE PERFORMED: OE$TRUCTION(choose type below) <br /> D NEW WELL l BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ��ll E OVER-BORE <br /> D SOIL BORING# PRESSURE GROAT <br /> 0 WELL# Grdul 6pecm adans <br /> 'Other' <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATIO TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGSt DYES D NQ WELL CASING DIAt__ <br /> 0 EXTRACTION D AIR HAMMER/D RIVEN CASING THICKNESS TYPE OF CASING D STEEL D PVC D OTHER: <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> D AIR SPARGE D PUSH POINT GROUT SEAL PUMPED'. D yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Sal.BORING OHANDAUGER GROUT SPECIFICATION$' <br /> D OTHER: 11 OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC 00X w D STOVE PIPE <br /> Q,Q CONDUCTOR CASING PROPOSED? (if YES,list spedfica5ons here): <br /> 'COMMENTS::-�S %L% i-'�"' "�� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 49 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 <br /> County ClTdinancesAules and Regulations,and all applicable California State Laws. <br /> signed x LL� TltklCompany��y <br /> Fdnt Name �'�s`-� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> 111/ ,A,�.t Oale Issuetl J I _Ames���3 <br /> AAPilranon Accepted By Dale <br /> Dale Final Inspection By <br /> Grnutinspeclbn Ey �'; OZ <br /> Destruction ins on ey Date <br /> COMMENT$ICON DITIQNS: <br /> ACCOUNTING ONLY: AID# ur« <br /> PE CODES FEE INFO AMOUNT REMRTEO CHECK# REC'D BY DATE PERMIT I SERVICE REOUE017 <br /> ICE <br /> aqua- hQ (�D B8(o i Dz sRs boz to <br /> Wc=WAIVER_ <br /> L-57 Letter of Authorization to sign permit_Encroachment doq 1/25/02 <br />