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1131 titl/LYJl7L 1U:41 ZtJJ4bt7J46J I'IF IH I-LULIK PAGE 04 <br /> WELLPERMIT APPLICATION FOM SITE <br /> SAN JOAQUIN COUNTYo � (��(` �iI�*#IGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT�F#Gp UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 AN 0 3 208�- <br /> (209) 468-3449 611 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE" %MENTHEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work desalbed. TVEW4'QEi�„'fl('a&compliance with San <br /> Joaquin County Development Title,Chapter 0-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> -r' y <br /> WELL location )lag- 1300 S. S/btraMlw¢u .St Cross Street TAnar��'/( ,U�A Y, Ctry Lo Assessors <br /> i T;p /i� & Parcel# COIfs—1Q49-0' <br /> PROPERTY Owner NeWCo /jofZ TIC_ Address &I S, SAtIA)Menf gS . City___l PJ, Zip 9V/0Phone# <br /> C-57 Contractor Gv e � l✓ofi lli h q Address MO YOW e t1at' City +rfh,c z ZIP�rj ucn65-6Y07 Phone#t 92 0 313-5800 <br /> Til <br /> Consultant/Sub Cntr Z. Address .�O,li aZ e c;-1 Afy Lownrd Lie# Phone# P9zQd88–/400 <br /> GIS Coordinates:X ,Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL.!BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTNER•) n DESTRUCTION (choose type below) <br /> }(SOIL BORING# Stl^ 1 D OVER-BORE. DIAMETER <br /> n WELL II n PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING j(HOLLOW STEM DIA,OF BOREHOLE I21M n MULTIPLE CASINGS 0MULTI-LEVEL WELL CASING DIA: NSA <br /> n EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS,TYPE OF CASING: Q STEEL Il FVC n OTHER: <br /> a VAPOR n MUD ROTARY DEPTH OF GROUT SEAL W & TREMIE TYPE TO BE USED: XAUGERS n HOSE <br /> a AIR SPARGE/OZONE aPUSH POINT(GP orCPT)GROUT SEAL PUMPED: a,Yes allo (NOTE: MAAXIMUMFREE-FALLDEPTH IS30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Nlern9�- �'etr.e�1 <br /> H OTHER: n OTHER APPROX.BORING DEPTH 7D T�—n BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (it YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> Count Ordinances, Rules R gulations,and all applicable California State LawGsr n ' <br /> Signe <br /> Print duvf <br /> Name�`'T�`'^y`'^� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> 4pptication Accepted/B r/`d'r�^-`-o'"� , Date Issued O� Area DV PiI�K�"tC,t_(� <br /> 3roul Inspection By I.Y Date "V93 <br /> Inspection By Date <br /> )estruction Inspection By Date <br /> :OMMENTS f CONDmONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REWD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# pX�3�1 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />