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07/07/2003 11:01 2094671-' 1.' AGE STOCKTON • PAGE 02/03 <br /> WE* 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) 468-3449 <br /> NON-REFUNDABLE PER EXPIRES t YEAR FROM DATE ISSUED <br /> Application hereby lo de to San Joaquin County for a permit to construct and/or install the tiwrk.8escribed. This appliratlon iy maria In compliance Mth San <br /> JoaquinCounty pri6t Tdle,Chapter 9.117 .3 and the Standards of San Joaquin County Environmental Health CoparItttent, <br /> WELL Loi tion�h()K�.�Cross Stmet µ� CI AssessoYs <br /> PROPERTY LSgo> <br /> kl�.,.,nlAddress ' q�_.�ip_11�a�l�Phone#(.,z0�Y3� <br /> C-67 Contractor C 1 Address CIty1W.n g zp/rj)W'Licat_„�...._F41one# <br /> Consultant/Sub Cntr�� 7' COf ouo. <br /> Address t�� y�_�y, City Lica , 0_SPhwis#, tp4) � <br /> GIS Coordinates:X ,Y.,Township <br /> Range___SecBon <br /> &gRK TO SE PERFORMED: <br /> A NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HANG-AUGER,OTHER'S Q DESTRUCTIONchcoae <br /> KSOIL BORING#_ J ( type below),. - <br /> "Ofharc <br /> WELL# N _ p OVER-BORE ' <br /> GOMMENTS Grout Specifications: Q11 I]PRESSURE GROUT,t-�l C_C�' h'1' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION 3PECIFICAT1pNg r/ <br /> AMONITORING -A-HOLLOW STEM DIA.OF BOREHOLE-52.MULTIPLE CASINGS? MU? <br /> ❑EXTRACTION II AIR HAMMER/DRIVEN CASING THICKNESS_• U TI-LEVEL?ff WELL CASING DIA: <br /> R VAPOR SL Yb _TYPE OF CASING: U STEEL XPVC 0 OTHER <br /> Q MUD ROTARY DEPTH OF GROUT SEAL L <br /> 0 AIR SPARGE/CZOne PUSH POINT -•- -1�•.11�TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> p GROUT SEAL PUMPED; XYes `&No (NOTE: MAXIMUrto FREE-FALL DEPTH IS 301)� <br /> SOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER:—Q OTHER _42U �"'�•-�'�•�.�,-+. �n OY'I l 1� <br /> APPROX.BORING DEPTH,_ SL.,/'.-y0`pg01 T8D TRAFFIC SOX or b STOVE PIP, — <br /> CONDUCTOR CASING PROPOSED? Of YES,list Specifications here <br /> 'COMMENTS: <br /> NOTE. OFFSITE 80RINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOUR 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 /> :ounty Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> fined x Tltln/Company 1�-�_:Ji J� t, r� / j <br /> riot Name Y}, _ i' �`] `-""�'�: uCd-1ELLoas�w <br /> DEPARTMENT US�g OMLy6 <br /> ITE MAP IN UNIT IV FILE, ADDRESS: <br /> /ORK PLAN DATED: —•-•�.�. <br /> Vffcadon Accepted 0y <br /> out Inspection By ate Issued A <br /> Date <br /> sn Inspection By Date <br /> trucdon Inapection �� ' <br /> )MMENTS/CONDITIONS: <br /> ,CCOUNTING ONLY: AID# -- <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# CID DA PERMIT!SERVICE 5T# INVOICE <br /> 573WG_1A/AIVER �4 ) 3 <br /> C-57 Letter of Auth zon to p mit_ _ Cncroerhment riot <br /> Gply , <br /> II�''// lr <br />