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toplicason Accepted By <br />rout Inspection By__ <br />)eatrucrion In,spection By <br />Mar-19-02 01:56P VIRONEX, INC. 510 568 7679 <br />03/19/2002 14: 34 2094683433 FIFTH FLOOR <br />P .02 <br />PACiE 02 <br />GO/UJILL,,,4 r I" rtvi, <br /> <br />a() <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 />SITE <br />MITIGATION <br />UNIT IV <br /> <br />Nom.AgFUNIGARLE pSRMFT EXPIRES 1 YEAR FROM DATE ISSVED <br />policaton hereby made to San Joaquin County tor a permit to construct and/or Irt3tat1 tr werk described. Thls application Is made In compliance with Sr <br />7aquin County De,elupmont TitM, Chaptor 9-1115.7., and the Standards of San Joaquin County environment* Healy, Gepartynent <br />-03° • Assessor's <br />JELL Location 04-SLQ - 46)(06'*••i12' /1(-\ft2"" Cram Street Oa-44'f City AA4L43ip parceut 7-19 019 0 <br />In-10 rerr-Pkau-l^s Vc‘, City A-'0 1+1 CYZ L.,2 ROPERTY Owner (in C- Address -1;•m Ztp Phartc.4)0 - 1-79 -44 <br />Aisdrtor. I 0 A lvaao ;074577 i j at 7652-7 pion.* cgl to& 67 I, <br />:-51 Contractor V iliY\-e-"Y <br />Addras6 LI 00 ..5 R,-{Chic2-1.±to ticA Pil°n" • -2.-1.1& 1E4)1 5 :onsultant Sub Contrector 1 -T Cr?,•:. <br />-rownshlo settton itS CoondlaaieS: X <br />VORk TO RE PERFORMEn- <br />t NEW WELL / BORING ( CT. COPRIDBE, <br />IL BORING - <br />HYDROPU NCH, HAND-ADGER, OTHER') <br />O Tic 1_ <br />DESTRUCTION (choose type below) type <br />WELL 0 PRESSURE GROUT <br /> Grout Spealcabons - Other <br />;OMMENTS: <br />YPE O WEI-I, INSTAJ„LATIoal TYPE <br />!MONITORING U HOLLOVv STEM <br />) EXTRACTION 11 AIR HAMMEIVORrVEN <br />VAPOR U Mut) ROTARY <br />AIR SFARGE fl PUSH Poirrr <br />ODA_ BORING fl HAND pucfZR <br />I OThER. JI OTHER <br />CO MM E NTS' <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YRS El NO WELL CASING 01A <br />CASING THICKNESS TYPE OF CASING: fl STEEL al PVC a OTHER; <br />DEPTtn OP GROUT SEAL, TREMIE TYPE TO SC USED: 0 AUGERS LI HOSE <br />GROUT SEAL PUMPED: [11Y193 (3NO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH BOLTED TRAFFIC BOX or OSTOVE PIPE <br />CoNDUCT9R CASING PFTP/I9.S. 601 (II /ES, LiST SPeCifiCeriOrS here) <br />jii) <br />NOTE; OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT W INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />hereby certify that / have prepared this application and that the work will be done in accordance with San Joaquin <br />:ounty Ordinanc Rules and Regulations,And all applicable Ca/lfornia State Laws. <br />x TiticoCompany_ (-0 1 /4(1.FX/ <br />AAN Date n 0 D. <br />DEPARTMENT USE ONLY <br />;ITE MAP IN UNIT IV FILE, ADDRESS: <br />MORK PLAN DATED: <br />'riot Niarne <br /> pato Issued fi 1/0 <br />Dote <br /> Date ../2-I97C7 2---- FinvlInspecton By <br />Area <br />Pate <br />:ommorrsr CONDITIONS nA 5 Di-'7 <br />ACCOUNTING ONLY: AID <br />—"1 <br />INVOICE PE CODES CODES FEE INFO AMOUNT REMITTED GHEGX a lilac° BY OATS M <br />3//q/(-2 <br />t sERVICE REQ <br />_____________ .1. 35-n r,kk a <br />IT <br />gt (Y))-1')-ezi .,.., <br />c-57 WC -WAIVER C-57 Letter of Authorization to sign per 'Encroachment doc lin/OR <br />03/05/02 TTJE 09:39 [TX/RX NO 54041 Q003