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07/19/2002 08:18 2094683433 rll iH I-Luuk r•AJE ut- <br />WELD HERMIT APPLICATION ARM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />MIT; Ir - [D) <br />N O V 1 3 2002 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED u <br />TH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is madeW#A#/RWV1* <br />wJoaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br />\ Acl J5 Assessor's <br />WELL Location 3 r��' k bme xc Of'_ Cross Street City C; n:� Wit; r_ _I Zlp '(5?a Parcel# 1 �\� -� 3G "Dig <br />PROPERTY Owner F AN OF ��u t c� Address W City " .4-:: 7v Zip Phone# L"'~� 1 L`I`1 ui t 1�9 <br />C-57 Contractor_TAP,c-X Address 'Sett U,p QwVM-r,1. kL City-L=Z r- Zip` 6i1 tic# 61 IGPhonetf "�1) <br />0 <br />Consultant/ Sub Contractor Ul—w-"S 7Dl�i' nJ Address `X�� 1 �� ST, S i��-r _,=ty C LN: Lid# Phon SIC Y-43 j cx, <br />CIS Coordinates: X , Y . Township Range Section <br />WORK TO BE PERFORM D- <br />( EW WELL ABORT GQ. , GEOPROBE, HYDROPUNCH, HAND -AUGER. OTHER`) p DESTRUCTION (choose type below) <br />Q SOIL BORING # a OVER -BORE <br />n WELL #- Q PRESSURE GROUT <br />'Other: r,- Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />n HOLLOW STEM <br />0 EXTPACTION <br />h AIR HAMMER/ORIVEN <br />Il VAPOR <br />0 MUD ROTARY <br />I1 AIR SPARGE <br />0 PUSH POINT <br />I..KOIL PORING n HAND AUGER <br />n OTHER: KTHER C -f �� <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE_ MULTIPLE CASINGS? Q YES &NO WELL CASING DIAi5 <br />CASING THICKNESS AIrt TYPE OF CASING: Q STEEL 0 PVC Q OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 'GAUGERS V HOSE �O <br />GROUT SEAL PUMPED: �Y� tNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />GROUT SPECIFICATIONS: v r F -,c ; T <br />APPROX. BORING DEPTH 100 I7 BOLTED TRAFFIC BOX or p STOVE PIPE <br />c <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />'COMMENTS: 1vt?Sil+"�FPC Ss�uE�.:s��+`�Ty <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />c:ALL TNF i INrr IV INSPF-CTOR dR WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordirtan As, [ales and Regulations, and all applicable California State Laws. <br />Signed x Title/Company <br />Print Name �rx.[.-Date!_' <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By,. Date Issued <br />Grout Inspection By Date U Zb VZ- Final Inspection By rrriii Date <br />Destruction Inspection By Date <br />COMMENTS 1 CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />Fnrs <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PE RMI EST # <br />INVOICE <br />003/q/0 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />