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02/19/2002 16:12 20946834 FIFTH FLOOR. PAGE 02 <br /> WELL ; ',ERMIT APPLICATION FORM SITE <br /> 02 �? F SAN JOAQUIN COUNTY MITIGATION <br /> ENVIF&NMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> )plioation is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> jaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> ELL Location 111941 c Cross Street ,aA RelCity ip Parcel# ?63-070 -0.78 <br /> r ,t 953 y <br /> 20PERTYOwn� t� <br /> e"r 6eA_C%1,.evt Ales Address �/07y/�tl�.cCont��v4z�Ic.�lty Zip� XS?S/ <br /> Phone# n - -.?4 <br /> Ge5$ <br /> •57 Contractor Tf�Z, A--Ar Address 10/4 6' ke—tA Xk� 4e CityZipCL7&"5 Lic#_;�Phon ?I y qS1_050 <br /> Dnsultant I Sub ContractorT T nmf Darr a(�'ern Address iZ.;26/V,ff& Ice �l vol Ciry erewuw Lic# Phone# 9/Ce-9?$-3�a'O <br /> s Coordinates:X ,Y Township Range Section <br /> ORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) n DESTRUCTION(choose type below) <br /> QGSOIL BORING# .2 n OVER-BORE <br /> p <br /> WELL# Q PRESSURE GROUT <br /> Ither: Grout Specifications: <br /> OMMENTS: <br /> !PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ,HOLLOW STEM DIA.OF BOREHOLE S;n MULTIPLE CASINGS?0 YES �NO WELL CASING DIA: <br /> EXTRACTION I]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: n STEEL n PVC n OTHER; <br /> VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: j]AUGERS n HOSE <br /> AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: a Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING n HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER: fl OTHER APPROX.BORING DEPTH .SO -C4 D BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (If YES,list specifications here): <br /> OMMENTS: <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 /> iereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> ounty Ordinances, Rules and Regulations, and all applicable California State Laws. 1 <br /> fined x 161 . -Y[ nsp. �, Y li Title/Company� IT- <br /> l�N�O:.L:1�o r► <br /> int Name Y U \Clylf, A Date <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE,ADD ESS; <br /> IORK PLAN DATED: <br /> :plication Accepted By, �" Date Issued 7/Z3t6L_ Are'f2 <br /> Inspection By Date Final Inspection By Date <br /> ntruction Inspection By Date <br /> .1MMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# Kar, <br /> 'E CODES FEE INFO AMOUNT REMfTTED CHECK# REC'D 13Y DATE PERMIT J SERVICE REQUEST# INVOICE <br /> SRO <br /> '-57 WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc 1/25/02 <br />