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02/26/2003 11:08 20946834 FIFTH FLOOR PAGE 02 <br /> APPLICATION SITE <br /> � �, <br /> 1! k--;'LMITIGATION <br /> � E <br /> SAN JOAQUIN COUNTY UNIT IV <br /> MAR 2, 0 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIROWEf,J 1 i ir_raLI i-+ (209)468.3449 <br /> . PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR EIROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to Construct and/or install the work described. This application is made in compliant with S <br /> Joaquin County Development Title,Chapter 9-1115.3 and the�S�tand�ard of San Joaquin County Enviro Antal Health De - Essor's �l <br /> WELL Location .�U�To two. . •• o r Sre weAM rr City wd( zip �j' 2 Farrel# <br /> PROPERTY Owne C ITV OF &(PM1 Address aJ� (,Jr�__city zip r57��Phone#L <br /> C-57 Contractor QGSo►uLn�-Soh i C Address ZOA F.avf�f- City p Lic# Phone# Z�FZ¢' <br /> Consultant/Sub CntrAddress OD � I ®CltyUo# Phone# g7BO 2 Ca9g2� <br /> GIS Coordinates:X_�� j. �,Y 2,D g .Tgwnship Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER'} g OVER-BORE <br /> OIL BORING# -3 — P ESSURE GROUT <br /> 0 WELL-A �/ Rt- <br /> '04her: Grout Specifications,_ -/i O <br /> 'm gkAtAiL— <br /> COMM-E—NTS aQ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES B NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC. 0 OTHER: <br /> 11 VAPOR a MUD ROTARY DEPTH OF GROUT SEALQZIP M TREMIE TYPE TO BE USED: B AUGERS -A HOSE <br /> []AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: ,Yes []Noj OTE: MNCII�UM FREE ALL DEPTH IS 30') <br /> XSOIL BORING ®HAND AUGER GROUT SPECIFICATIONS:®.set,r �• ® NG,q, �/►��'IL <br /> 0 OTHER: OTHER 50AI 'APPROX,BORING DEPTH 2W _0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list 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 /> I hereby cKe <br /> t I e prepared this application and that the work will be done in accordance with San Joaquin <br /> County Os Rui and Regulations,and all applicable California <br /> 22State Laws. <br /> Title/Company �%l� 44 <br /> Signed x �/ p / <br /> Print Name $ Date�1 `!d s <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: t 6L t <br /> WORK PLAN DATED: Z <br /> Application Accepted By � Date Issued � Area �C '� <br /> Grout Inspection Byt-�/ r ` Date 6 Final Inspection By�` Date �' b <br /> Destruction Inspection By Date <br /> COMMENTS J CONDITIONS: <br /> e.n est os,5 b le -{vt rh I <br /> ACCOUNTINGONLY: AILM cnr`tt <br /> PE CODE$ FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT J SERVICE REQUEST# INVOICE <br /> b ( 17C7 SIR# 333 <br /> C-57`. WC--:-WAIVER— C-57 Letter of Authorization to sign permit—Encroachment doc_ I�25�o2 <br />