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02/10/2003 14 05 209468343 FIFTH FLOOR PAGE 02 <br /> WELL, PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> • ENVIRONMENTAL HEALTH DEPARTMENT(EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) ""449 <br /> NON-REFUNDABLE PERMIT EXI!DtFS 1 YEAR FROM DATE ISSUED <br />%ppticalon Is hereby made toSan Joaquin County fora permit to construct andl*r inaWl the work described This application is made in compliance with San <br /> loaquin County Development rifle,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> HL Location 3 Cross Street v �p tIGV 2026L­;Ass <br /> ELarOctF 4 -e310501 7p <br /> City�T_.. '30 <br /> IFIOPERTY Owner 441d/ak £-KV&S--el LLC Address I&ftasTu grdr Cty 77�s >5tson� <br />..47 cornraao • dgs? Moc Rd crltrcp ic# Fq � LP34-58.40 <br />:�onsulta t/Sub Cntr r ddress P.a•8a # Phone#747-X33 Z 3 <br /> 0 Coordinates .Y q� 4L Range Section <br /> N_OR K TO BE PERFORMED- <br /> NEW WELL 1 BORING (GPT,GEOPROBE,HYDROPUNCH,HA*F�r P40Z@g8j DESTRUCTION (choose type below) <br /> d SOIL BORING# II OVER-BORE. DIAMETER <br /> ly WELLFIESSURE GROUT <br /> 4 r1p cat 11k9 <br /> d*Omer NVI )dME ,C HEALTH GRSPCFCATONS <br />'OMMENTS PEAMIT/SERVICES <br /> EPS[ OF WELL INSTALL4MON TYPt; CONSTRLIQMN SPECIFICATI S y <br /> I MONrrORING li HOLLOW STEM DIA.OF BOREHOLE_I_ [I MULTIPLE CASINGS ]]MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION lI AIR HAMMER/DRiVEN CASING THICKNESS TYPE OF CASING XSTEEL [I PVC []OTHER- vd <br />]V R a MUD ROTARY DEPTH OF GROUT SEAL � -TREKTYPI;TO 8E USED []AUGERS O HOSE ­31 I ARGFJ OZONE [I PUSH POINT(GP or CPT)GROUT SEAL PUMPED 'Yes I]NO (NOTE; MAXIMUM FREE-FALL DEPTH IS 30') <br /> 3 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS IA <br /> t <br /> XOTHER 598 Rig n OTHER fA AkI00VM APPROX BORING DEPTH,--LI-5" -,Yg BOLTED TnAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list spec ftmons In comment section) <br /> 30MMENT'S• <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that 1 have prepared this app[icatlon and that the work will be done in accordance with San Joaquin <br /> County Ordinan les a egUlations,and all applicable California State Laws <br /> Signed ' Tltle/Company <br /> print Name orf' Date <br /> �..,lr o <br /> gr <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: -_ <br /> mon Aooapteid By1 � _Date isaued Zl o fix a LPp q i 71a <br /> Srout Inspection t3y — - _ Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENT81 CONDMONS <br /> ACCOUNTING ONLY AID# FAC# <br /> F DES ME INFO AMOUNT REMr1 TED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3sQ� 6O` 6d' t L�o is o SR# poi Z?a <br /> C-57 WC -WAIVEI2-- C-57 Letter of Authorization to sign permit Encroachment doc 4/30/02 <br />