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10/13/2003 13:59 714-630-2987 <br />TRIHYDRO ANAHEIM <br />WELL. PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />PAGE 02 <br />SITE <br />MITIGATION <br />UNIT IV <br />NON -RE UNDABLE PERMIT EXPIRES 7 YEAR FROM DATE IS ED <br />Application Is hereby mode to Sen Joaquin County for a permit to construct and/or Install the work described. This application Is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County^ Environmental Health Department. <br />WELL LocatiorgQS� � `t`/ Cross Stmet�OAM • City 3raG j� Zip! Assessors , 2 D <br />Parcel# <br />PROPERTY <br />C-57 Contractor <br />7"09 <br />S68 -1`06 <br />Consultant l Sub Cntr r E t rass Ai A � Ei y Llc#� Phone lk%k IZB341-1 <br />CIS Coardinstea: XSeq- , Township Range Section <br />WORK TO BE PERFORMED; <br />p NEW WELL / BORING r� CPT, GEO R0SE, HYDRQOPUN , HAND -AUGER, OTHER") 0 DESTRUCTION (choose type below) <br />,YWELLBORING # . tit r l] O p ti [, OVER -BORE. DIAMETER _ <br />SURE GROUT <br />0 "Other,/ 2- �h� ROU TSPECIFICATIONS <br />COMMENT'S: �C Y <br />TYPE OF WELL INSTALLATION TYPE CONAIRLMON SPECIEIMTIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA, <br />Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 0A TYPE OF CASING; 0 STEEL )rVC 0 OTHER; <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALd � TT.�. TREMIE TYPE TO BE USED: 0 AUGERS )rPOSE <br />a AIR SPARGE! OZONE POINT (GP or CPT)GROUT SEAL PUMPED; p Yea w0t,N,o. (NOTE. MAXIMUM FREE -FALL DEPTH IS 301) <br />SOL BORING 0 HAND AUGER GROUP SPECIFICATIONS <br />0 OTHER: 0 OTHER _ APPROX. BORING DEPTH_- < 0 BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED (If YES, list speclfleations in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, RullAs and Regulations, and all applicable Callfornia State Laws., <br />Signed <br />Print N; <br />4 rl <br />SITE MAP IN UNIT IV FILE, ADDRESS; <br />WORK PLAN DATED: <br />Tltle/Company, <br />C <br />ADDlication Accepted By Date Issued <br />l% S—/o � Area <br />Grout Inspection BDate % D Z/ 02 Final Inspection By Date <br />Destruction Inapection By Date <br />COMMENTS/ <br />ACCQUNTING ONLY: I AID# <br />Gvkl')a <br />II PE CODES I FEE INFO I AMOUNT REMITTED I CHECK # I REC-0 BY I DATE I UE$T#,, I INVOICE 11 <br />.� fb I I 1- I M - I 3yrs�-Z I /-qc I CDS <br />SR#Dv3���7 <br />C-57____• WC_ WATVEk C-57 Letter of Autharixotion to sign permit_ Enc ent do 9/30/02 <br />