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10/08/2002 10:47 2094683433 FIFTH FLOOR PAGE 04 <br /> pL PERMIT APPLICATION FORM 817E <br /> ) SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> JAN 2 4 20904 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH (209) 468-3449 <br /> PERMIT/SERVICESNON-REFUNDABLE PERMR EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San <br /> Joaquin County Development 7100,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> 1y'PAA A:ea♦✓-04-,,.•y n4j-r'- - / q Assessors <br /> WELL Location to 1119-1320 S. �,.,Jn,.e.4. c+. Cross Street p Ciry o.tt r zip /S��� Parcel# A/1A <br /> PROPERTY Owner_Univn Pa[,(,c AAdy,rk Address /Vo r^rna,., St. City Ann NZip SP/OZ Phone# <br /> C-57Contraclor (ry� � I�rr ll�.,� Address 150 ltowi 94 City a, '„e Zip /�5Sr31.idr MPhone#C92S) <br /> Consultant/Sub Cntr TRS _Address)-051 t0,n,hert/nI (irrifC Ciry ✓azar&{ Lic# Phone# C <br /> GIS Coordinates X---,Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> A NEW WELL i BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) H DESTRUCTION (choose type below) <br /> III SOIL BORING# S'3 - <br /> B - I I H OVER-BORE. DIAMETER <br /> `WELL#„ SA -Ti ZY CAA -� 1]PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> rI <br /> MONITORING I{HOLLOW STEM DIA.OF BOREHOLE /,r� H MULTIPLE CASINGS H MULTI-LEVEL WELL CASING DIA: _ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS StA, y-0 TYPE OF CASING: H STEEL S PVC n OTHER: <br /> H VAPOR n MUD ROTARY DEPTH OF GROUT SEAL b-50 j f, TREMIE TYPE TO BE USED: J AUGERS 11 HOSE <br /> a AIR SPARGE/OZONE I PUSH POINT(GP or CM GROUT SEAL PUMPED: III Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> n SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS )Vent tta,e„.' <br /> H OTHER: 0 OTHER APPROX.BORING DEPTH 7o t-P. II BOLTED TRAFFIC BOX or U STOVE PIPE <br /> n <br /> CONDUCTOR CASING PROPOSED A/0 (if YES,list specifications in comment section) <br /> COMMENTS: lr ea 0 r.l9 V5'!Lt ar Sig -tai , 10 fi, :L l htat tewenf69ra'L _ <br /> NOTE: OF SITE BORINGS REQUIRE CCESS AGREEM NT 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 /> County OFdia nees, Rules and ti s, and all applicable California State Laws, / <br /> Signedx ,y�n'-�" Xr"�� Title/Company ArV'e V016 21' A 'rz Tj2-e <br /> Print Name �M� �T,t'`' 1 I Date ((�3I 03 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDR)rSS= <br /> WORK PLAN DATED: GIJ I-L'k�V C-A) QLAAh , � / <br /> application Accepted By. '- /Date Issued I �1b3 Area C(�Ge-t"UT OL <br /> 3roul Inspection By '11� Date / Z'Gbf Final Inspection By Date <br /> Destruction Inspection By Date p <br /> : RI <br /> OMMENTS/CONDONS; U p D <br /> ACCOUNTINGONLY: AID# - FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 361 8�t - l �7� /JfG o SR# ZS 3S' <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />