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03/24/2003 14:46 <br />MAR 2, 4 Z003 <br />0VIPUNIVi�_NT HEALTr <br />P RMIT�SER��IC�S <br />2094671118 <br />AGE STOCKTON <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EMD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />PAGE 02 <br />SITE <br />MITIGATION <br />UNIT IV <br />L 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 />ioaquin County D,evrjelo(p,,/men`t Title, ,Chapter <br />�9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />NELL Location f w V! Sid, A6,Lvy Ave—U Cross Street f7J2 ar.Ci � l zi Assessor's <br />Qty p�Parcel# <br />7ROPERTY Owner -G Address JJ/�� ✓ //!! �d7l��i/�/Ci��tytt 5 � Z;&jZ Phon y 93 7 7 <br />-57 Contracteryjr� ✓)~SA d ess /� Luh 17y�L� ly M�LZi� c#�rPhoncp� 3� 3 5 <br />�� Ci p_ 3L' �# <br />:onsultdnt 1 Sub Cntr AddressTJr�G�u �G' CEty ��f=�� Licit PhoneUg y ���k� <br />315 Coordinates: <br />Y <br />Township <br />NORK TO BE PERFORMED' <br />NEW WELL / BORJNG (C�GEOPROS3 , HYDROPUNCH, HAND -AUGER, OTHER`) <br />0 SOIL BORING ## <br />0 WELL # <br />Other: <br />'.OMMENTS <br />Grout Specifications: <br />Range <br />Section <br />0 DESTRUCTION (choose type below) <br />(I OVER -BORE <br />CI PRESSURE GROUT <br />'YPE OF WELL INSTALLATION 'YPE CONSTRUCTION SPECIFICATIONS <br />I MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE -IPLE CASINGS'? 0 MULTI-LEVEL? d WELL CASING DIA_ <br />I EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS A! f�- TYPE OF CASING' 0 STI=L=L a PVC 0 OTHER: l� <br />VAPOR (] MUD ROTARY DEPTH OF GROUT SEAL l.r24&. TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />] AIR SPARGE / Ozone GUSH POINT GROUT SEAL PUMPED: Ines 00 No, NOT MAXIMUM FREE -FALL DEPTH IS 30') <br />}'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br />I OTHER__o OTHER APPROX. BORING DEPTH I?? Il t3UL7E 0 TRAFFIC BOX or p STOVE PIPE <br />�n CONDUCTOR CASING PROP05Ep7� (if YES, list specifications here): <br />COMMENTS: <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 Ordlinances, Ru ® nd Regulations, and all applicable California State Laws. <br />iigned xqq�� )� Title/Compan <br />!/(/ <br />'rint Name � / /C6 (�/ /7 Date <br />DEPARTMENT USE ONLY <br />iITE MAP IN UNIT IV FILE, ADDRESS:9 _ A), <br />MORK PLAN DATED: <br />\pplieation Accepted By Data Issued 2 a Area <br />3rout Inspection By Date `4l O Final Inspection By Date <br />)astruction Inspaction By Date <br />.OMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PF QUEST # <br />INVOICE <br />-3/ 2so3 S po 33 l5 <br />-57 WC -WAIVER C-57 Letter of Authorization to sign permit a i�u►eflt doer 8/29/02 <br />1k <br />