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05/20/2002 09:20 <br />2094683433 <br />FIFTH FLOOR <br />WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEj <br />304 E. Weber, Third F <br />(209 <br />PAGE 01 <br />Post-itr Fax Note 7671 <br />Dares <br />pages <br />To 0 t Yom—! <br />From <br />CaJDapL l�t�C. Pt1— <br />Co, <br />Phefl '41 O - C / j <br />O b <br />Phone # <br />Fax # <br />Fx it <br />NON-REFUNDABLE PERMIT <br />—aplication is hereby made to San Joaquin County for a permit to construct In <br />Joaquin County Development Title, Chapter9-1115.3 and the Standards o1~ ., ,. -- _ _ .. _ . _ . <br />V� Easy jOStKiy'ryC_ Cross Street City P Assessors <br />ELL Location f/� ���� Z 4 S7 Parcei# <br />PROPERTYOwner//T BCW of >✓I Address 5 �- �Citty�l� - ! zip 0 �cphone# 2� ia3-3fi� <br />-57 Contractor_ j1' 1e1 Af�e 1 'e1— Address '% �� Sf city �7 4 zip Llc# �G��Phone# ��' �Y4 `/3YS" <br />A <br />consultantlSub Contractor �ril#.C?r11�='i Addre <br />a r°�+C'WtL�Clbj_S�icJ� Phone# Ca ��"" <br />lS Coordinates: X , 'l , Township Range Section <br />� PERFORMED: <br />NEW WEU21 BORING ( CPT, GEOPROSE, HYDROPUNCH, HAND -AUGER, OTHER-) p DESTRUCTION (choose type below) <br />B SOIL BORING # Q OVER -FORE <br />/ fl WELL �. J 0 PRESSURE GROUT <br />ether. M10014ri NQ G��t V-- Grout Specifications: <br />COMMENTS: <br />P OF <br />Y-"MONITORING <br />INSTALLATION TYPE <br />=WELL- <br />ONM ITORING <br />HOLLOW STEM <br />p EXTRACTION <br />1) AIR HAMMER/DRIV5N <br />VAPOR <br />0 MUD ROTARY <br />AIR SPARGE <br />0 PUSH POINT <br />p SOIL BORING <br />p HAND AUGER <br />OTHER:—D <br />OTHER <br />'COMMENTS: <br />CONSTRUCTION SPECIFICATIONS / Jt <br />DIA. OF BOREHOLE g r MULTIPLE CASINGS? 0 YES W<0 WELL CASING DIA: °Z <br />CASING THICKNESS 7 TYPE OF CASING: [I STEEL �VC BOTHER; <br />Di PTH OF GROUT SEAL — g TREMIE TYPE TO BE USED: P AUGERS OSE <br />GROUT SEAL PUMPED: eyes p No (NOT MAXIMU FR E -FALL DEPTH IS 30' <br />GROUT SPECIFICATIONS: e -qBoj-r -W 6r�jw'th -9u% LO'1 <br />APPROX. BORING DEPTH 30 0 BOLTED TRAFFIC BOX or B STOVE PIPE <br />CONDUCTOR CASING PROPOSED? No (if YES, list specifications here): <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 />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />31gned x -�/- Tide/Company <br />'Tint Name )r�;met- X de -q PL/ <br />SITE MAP IN UNIT IV FILE, ADD <br />WORK PLAN DATED: Cb 1-{ 1 -2-' <br />kpplication Accepted By L <br />Grout Inspection By <br />Date Issued_I ?®� Area <br />Date Final Inspection By Date <br />7estruction Inspection By <br />Date <br />COMMENTS 1 CONDITIONS: <br />ACCOUNTING ONLY: AID# FACIIA <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DA/TE,�( PERMIT! SERVICE REQUEST # INVOICE <br />C-57 WC= WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />