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07/21/2003 15:41 2094GA�133 FIFTH FLOOR PAGE 02 <br />WELL,- IERMIT APPLICATION Ff cm <br />SAN JOAQUIN COUNTY <br />2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA,, 95202 <br />F.�1VIR0(��J1ENT HEALTH (209} 468-3449 <br />P RMtY/ScRVIGES <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUN13ABLE PERMU EXPtRES 7 YEAR FROM DATES ISSUED <br />ipli©tion ;s hereby made to San Joaquin County for a pe,trrit to CUMUvi:41 and/or ;nstll the work described. This a <br />iaqu;n County Development Title, Chapter S-1115.3 and the Standards of San Joaquin County CnVironmentdl Healy(. epartment iS de in gnr:l;anc8 yvith San <br />�/ �// �} C <br />ELL> Ovation :%Y�O ,r% % yys_-73'/T crass sheet wy 7 c;ty Z1p Par e z;'_! <br />20PER7Y Gomer nI .%-'j`pddrew�Z /tb✓/M++ : C;ty TipfT3_-!EPho,,0 j Z` 3; Z / <br />sr CentraCnr rf �tl Address $31� C`} C1ty Mt9fJi Z:p UCS c�1�5�4XPhoneg-- aS • O Z <br />msultant 1 Sub Crrtr /� t 7� Address�CityL;c Phone# <br />S Coordinates: X Y TawnsN Range Secftn <br />IRIK TO BE PERFORMED: <br />qFW WEL' f BORING ( CPT, GEOPROB>_, HYDROPUNCH, HMO -AUGER, OTHER-) AESTRiJCTION (a7„v5e type belew) <br />R SER. BORING # d OVER-WRE <br />:ner. <br />)MMENfS <br />MWE <br />PE OF WELT- IN; ILA tITION TYPE CONSTRUCTION SPECIFICATIONS <br />IONiTORING Q HOLLOW STEM DIA. OF BORFiH<,L`�__MULTIPLE CASINGS? Q MULTI-LEVEL? a WELL CA; ING DIA: <br />!XfRACTiON D AIR HAMMER/DRWEV CASING THICKNESS , TYPE= OF CASING: it STEEL G PVC O OTF ER: <br />'APOR 0 MUD ROTARY DEPTH OF GROUT SEAL, _ _` TR2=WE TYPE TO BE USED: []AUGEr:S a HOSE <br />IR SPARGE 1 Ozone Q PUSH POINT GROUT SEAL PUMPED: Q Yes p No (NOT, 1=_ MAXIMUM FREE -FALL DE=PTH IS 30') <br />OIL BORING D HAND AUGER GROUT SPECIFICATIONS: - <br />int: n GiTiER APPROX- BORING DEPTH i. -r Q 901 -?-E'.7 TRAF IC HOX ar d SI OVE PIPE <br />CONDUCTOR CASING PROF0SED?__J� j if YES, fist speeflcatorm Here)._ <br />)MMENTS: (:71x%7 G�Irzr�t�- /t%lI'/ 66x_1 Z�, /L/fCl �i <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 />ireby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />unty Or ncas,,Ruies Regulations, and all applicable California State Laws, <br />led x Trtie/CmRparty U / /�7Zf ��%!/%' r11�10" <br />t Name Date <br />DEPARTMENT. USE ONLY <br />>; MAP IN UNfT tv FILE, ADDRESS: N , 0 ,F. '/o se cM <br />IRK PLAN DATED: . ) I AL -7_ (. 7nn -A <br />u % f <br />/cation Assxpted B}r Date Issued <br />K Inspectlon By Date Fina! Inspection By �- Date <br />ruction Inspection BY Date <br />IMENTS / CON <br />COUNTING ONLY <br />watt <br />CODES <br />FEE INFO <br />AMIOUNT REmrrrED <br />CHECK # RECD BY <br />DATE <br />PERMIT I SERVICE REQUEST # <br />INVOICE <br />0 <br />3 `f Gl y <br />T WCC WAIVER C-57 Let't'er of Authorization to sign permit <br />Encroachment doc 8129/02 <br />r <br />