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09/25/2002 13:16 <br />2094683433 <br />FIFTH FLOOR <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />PAGE 03 <br />SITE <br />MITIGATION <br />UNIT IV <br />"N U\��oV01 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />-NV\R0� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM 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 compliance with San <br />Joaquin County Development Title. Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department- <br />3)) <br />tr E R MAN Assessor's <br />WELL Location , j) l MO F F A"t $ Ly �, Cross Street AV C (I V E City MAN TE C A Zip 9 S 33 g Parcet# ZZ 1 - C 3 02 <br />PROPERTY Owner CINC (L(t(E5 M> -MT• 0EP'i Address 't111 e.5CCrtS AV 11 -City yTCLtc1CN Zip 9 20%Phone#09),4C8-33S} <br />VALLE Y <br />C-57 Contractor i'ISC1 i NV. Address iJ'I &IIVtAt'5 PLACE CltySiN(:J Zlp`)SIS',Lick�B?.S Phone#(1Q9) 172-3S7 <br />tinhcNti <br />Consultant / Sub Cntr P\A to A 4-C � Ny . Addrass P C 16 X i r " Gry MV AI el Lic#F I:C l Phone# L510 3 S'f -115 C <br />9,Sbt3 <br />GIS Coordinates: X —'Y Township Range Section <br />, '--r`V TIl Sir P`-'RF0P M. E D: <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) p DESTRUCTION (choose type below) <br />SOIL BORING # u, t - ` Q OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />'Other Grout Specifications: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE A - I N MULTIPLE CASINGS? 0 MULTI-LEVEL? p WELL CASING DIA: N A <br />0 EXTRACTION U AIR HAMMER/DRIVEN CASING THICKNESS N A TYPE OF CASING: 0 STEEL n PVC 0 OTHER <br />,— <br />a VAPOR o MUD ROTARY DEPTH OF GROUT SEAL T D: Z 5 --4 51 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE / Ozone I PUSH POINT GROUT SEAL PUMPED: a Yes ONO (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />1 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS' HE A T 4 k M C N T <br />Q OTHER 0 OTHER APPROX. BORING DEPTH 25 .'t 5 ' F r- 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? IY C (if YES, list specifications here): <br />'COMMENTS: S P' E r is 4h S t3 } `e [ '/- � r <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 />'.ounty Ordinances, Rules and Regulations, and all applicable California State Laws. �1 <br />1—---Tlbe/Company_, ' t— n V ( o"W rrW <br />'ntNae ���%) �! r 1�J//' Date <br />nmI ieJ'4Z <br />;ITE MAP IN UNIT IV FILE, ADDRESS5 M U F F Al g C '; L t<y IN R V M A N T k LA <br />YORK PLAN DATED: "1 1 1 E,,( C I <br />,pplication Accepted By -")N' -�Iwleyn Date Issued— I L Area <br />rout Inspection 8Date ' Final InspectIon By I f y1 Y'r/�- Date 2 <br />lestruction Inspection By Date <br />.arc . r�un�T�nNC" <br />ACCOUNTING ONLY: AID# cnry <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PER T1 <br />INVOICE <br />/29/02 <br />-57— WC= WAzVER__ C-57 Letter of Authorization to sign permit—E'ncrGachment doc_ 8 <br />