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07/12/2005 16:15 9167867 ENGEO INCORPOR T) PAGE 02/05 <br /> 07/12/2005 14:86 20043 EHD PAGE 03 <br /> WELL PERMIT APPLICATION FORM SITE <br /> - MITIGATION <br /> SAN Jt),4QUIN COUNTYMITIGATION <br /> IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 85202 <br /> (209)468-3449 <br /> NON REFUN 10606E P RMn"t,C211 ES K YEAR PPOM DATE tSSUED. <br /> AppllcatIon is Tterehy made to Sion Joaquin County for a permit bo conAtruct�nd/er lnmtall the work described. This application is m2de in oompilance with Sen <br /> .Joaquin County DevelopmsntTice,Chaptsr 9-1115.3 and the Standards of San Joaquin Count' Enviironmwtel Health Department <br /> ,.. a ��"� Aasngsaft <br /> I J I I,i R+:l,f rn.,:StrPPt R r"a..�a Citv/OCLL 4'2/ «o Parcew__O r3-0 70- 0 3 <br /> < ItGA <br /> PROPERTY Owner e- p Y Phare _ _..��ree�— � <br /> C-57 Contractor V1 W On7[���Addreas l oe 6��� �rr4 City J �p LiCii thane# <br /> Consultant 1 Sub Cantractnr _fj.Ls�`�ddress� I �'�7/�9Q1�e? �Ubity I�+r!'t/!/le LiC'# Phone# 6T11� 7�f�" : <br /> GIS Coordinates: .Y Township Range Section <br /> WOR T PERFORMED-, <br /> ` NEW WFLL I BORING(CPT,OEOPP.OBE,HYDRORUNOH,WAND-AUGER,OTHER-) Q DESTRUCTION(choose type below) <br /> !�' p SOIL BORING#t pV>:R 80RE <br /> WELL#- [yr <br /> •t�NhAM• Grout Specifications- p PRESSURE GROUT-- <br /> COMMENTS: <br /> n2 O0 t1uELLU= INSTAL.LA710N TYPE CONSTRUCTION SPECIPICATIQNS <br /> MONITORING HOLLOW STEM DIA.OI-MOPP-HOLE 10 ;N. MULTIPLE CASINGS?Q YES )(NO WELL CASING DIA;�/+J. <br /> EXTRACTION p AIR HAMMSFjDR1V-cN OAS] TSICKNFstj .y� TYPE OP CASING: 0$ EL PVC (�tDTNER' <br /> 0 VAPOR t3 MUD ROTARY DEPTH OF GROUT SEAL)/7 _.�TREMIE TYPE To BE USED: AUGERS 0 HOBS <br /> 0 AER SPARGE PUSH PRINT GROUT SEAL FUNIPJ:D; )Yes Q No (NOTE: MAXIMUM FRE&PALL DEPTH IS 30! <br /> 0 SOIL BORING 13 HAND AUGER GROUT SPECIFICATIONS: !'JPsA <br /> __. n000rlY enDttiir nC671-7 /ra .eft- n rtAt TPI)TRAFFIC ROX or TOVE Rlpl= <br /> ao CONDUCTOR CASING PROPOSED?_,dL-A_(if YES,list spedfieatians here); <br /> "CAMMENTS —m_.T— ��-- ----- <br /> NOTI=: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> herebysertity that I have prepared this application and that the WOrX will be done in accordance With San Joaquin <br /> County Ordinances,Mules and Regulations,and all applicable California State Laws. y- <br /> Signed _ Tit�eJCvmparly �/y _e -F `'�C. .� {'�' � ��•• a. <br /> PrPrttNama �c t'� �r Oate -21l <br /> 2-10 sr <br /> DEPARTMENT USE ONLY <br /> SITE MAP(N UNIT IV FILE,A130MESS: <br /> WORK PLAN DATED: <br /> ApprrAUOM Accepted By <br /> Da#e Issued 7 �3 D� �q <br /> Grant Inspection■Y Dare Final In"don By Oats <br /> Dr3cJfttetlan Inmpection By Date <br /> COMMENTS 1 CONDITIONS: ek <br /> ACCOUNTING ONLY: AID# Fcrf! <br /> Pp.CODES FEE INFO AMOUNT REMITTED CHECK 0 RECD BY DATE PERMIT SERVICE REQUEST P INVOICE <br /> C-57 WC-WAIVER C-57 Letter of Authorization to sign permit_Encreachmartt dOc.. 1/'�5� <br />