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11/08/2002 08 49 2094683433 FIFTH FLOOR PAGE 02 <br /> IE " vau <br /> Proteet'No -7 LL PERMIT APPLICATION FORM SITE <br /> P -,/ BF SAN JOAQUIN COUNTY NOV 0 7 20CMITIGATION <br /> Ro .1-1 EN RONMENTAL HEALTH DEPARTMENT MENT NEWT IV <br /> 16: <br /> —3-4_5___6;; <br /> E. Weber, Third Floor, Stockton, CA , WT/SERV <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to Construct andfor install the work described This applicabon is made in compliance with San <br /> Joaquln Count,Development Title Chapter 9 1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> �t gyp,,,.. �,A,� Assessors <br /> WELL Location 4 tAt6 �exStin� Cross Street ill l �Yt�. City S�GK�oVI zip Parcel# <br /> PROPERTY Owner S 1111 t+ S�Y1C�1/'<t,tr _Address 2 -1`7 CVcS�'-k.-0r: City s{rt,VQlle zp9�i552 Phone# 510-")10-5100 f <br /> '1 S" <br /> C-57 Contractor t/' it in�A_Address City 1 �Er �P zlp°J �'3 I,rc#Jc�`r=Phony "3l�"5goa <br /> Consultant/Sub Cntr lM�7ti`1.A-L"V Address 2-70 �G'"k �'^S 5A _Clty So-in6w?-, Vc# Phone# 70-1-9 3-5-46G0 <br /> GIS Coordinates X 'y Townshlp Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL 1 BORING (CPT GEOPP.OBE,HYDP,OPUNCH HAND-AUGER OTHER') y B611ESTRUCTION (choose type ba-low) <br /> a SOIL BORING# a OVER-BORE DIAMETER <br /> p WELL# k24'RESSURE GROULoY#�z�nd <br /> 0*Other GROUT SPE Ci FICATIONS_}' ! <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPE IFICATIONS <br /> vgIGSONITORING Q HOLLOW STEM DIA OF BOREHOLE a MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA <br /> Q EXTRACTION Q AIR HAMMERJORIVEN CASING THICKNESS TYPE OF CASING Q STEEL Q PVC Q OTH€P <br /> OR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIETYPE TO BE USED 0 AUGERS Q HOSE <br /> SPARGE(OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED p Yes p No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER 0 OTHER APPROX BORING DEPTH Q BOL ED TRAFFIC t30X or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES IEst spec,ficatlons 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 h e p epared this application and that the work will be done In accordance with San .Joaquin <br /> County Ordr , U In ReE ons, and all applicable California State Laws <br /> Signed x Tille/Company <br /> Date <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS <br /> WORK PLAN DATED/'( liYf <br /> AppGgLon Accepted BY r`•ww7 - -- Dale Issued �j / Are <br /> Grout Inspection By Gate Final Inspection BY Dare <br /> Destrudlon Inspection By Date <br /> COMMENTS f CONDITIONS <br /> COUNTING ONLY AID# FAC#! <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST INVOICE <br /> SDz— �b �o� Ziac tri-7 o z✓ sR# ods r 833 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permitEncroachment doc 9/30/02 <br />