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02/19/2002 16: 12 20946830`'? FIFTH FLOOR PAGE 02 <br /> WELL 'PERMIT APPLICATION FORM SITE <br /> 02Ap 2� h MITIGATION <br /> Pp, SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRCiNMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4pplication is hereby made to San Joaquin County for a permit to construct and/orinstall the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> HELL Location /014(e/ i5% Sig Cross Street City ip Parcel# 1D3-0740 -Oag- <br /> /' (( ,1 95 <br /> PROPERTY Owner 6,eAt��;e v t Al Address �(/D 7/�.cSaA�tuCr4z.yc.�lty Zip Y Phone# .I05 5'2S/-?95$ <br /> C-57 Contractor Eta>TtfAZ - Address���6 �' �:� f /tPt CityLZip�i' 4 i LiciPhone 7�y 93� ��D <br /> Consultant/Sub Contractor -x (7rn[Da. %4 w-, Address 1.3.26 V,(I,,,k,ius�Cilycrone- Lic# Phone# 9/(n-9?$-33ap <br /> :SIS Coordinates:X Y Township Rang® Section <br /> NOR.K TQ BE PERFORMED: <br /> NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 11 DESTRUCTION(choose type below) <br /> [)(SOIL BORING# .2 n OVER-BORE <br /> U WELL# (]PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> �OMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING K'HOLLOW STEM DIA.OF BOREHOLE S;n MULTIPLE CASINGS?0 YES )I/NO WELL CASING DIA: <br /> U EXTRACTION I]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: I]STEEL 0 PVC o OTHER: <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS p HOSE <br /> 0 AIR SPARGE n PUSH POINT GROUT SEAL PUMPED: I]Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> p SOIL BORING n HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: []OTHER APPROX.BORING DEPTH -5'0 -P4 U BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (If YES,Ilst specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> -�( <br /> Signed x i � Apa,..,, Y Title/Company h t I 1� ("% ","-'A,✓A <br /> /�� � <br /> 'riot Name [1 A ctL-(, l��t�L-, Date 1 o-)— <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> iNORK PLAN DATED: <br /> kpplication Accepted By��� d�"4 Date Issued--,//,L-3 16L— Are 195- <br /> Stout Inspection 8y Date Final Inspection By Date <br /> destruction Inspection By Date <br /> 'OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> rnr`x <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SRS <br /> C-57 WC -WAIVER— C-57 Letter of Authorization to sign permit_ Encroachment doc 1/25/02 <br />