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P:2/5 TO: 19163634084 MAY-20-2002 03:17P FROM: <br />C-57 WC -WAIVER C_71.7. Letter of ..iitALtho Tit n <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 498-3449 <br />ti_gtiajoaD&BLE PERMIT EXPIRE MAR FROM DATE ISSUED kpolicaLion is hereby made to Si, Joaquin County lor a wren to Oonotruel end/or Install the work described. This eppiicetion is made in eompiionca win San <br />loaquin County Development Title, Chepter 0-1115.3 and the Slanders of San Joaquin County PubIle Hearth Services. environmental Health Division. <br />Z° idooDOR% 06a Po <br />PROPERTY Owner ('-‘cairin. 1::104.5e <br />-67 Contrector <br />Consultant / Sub Cor1t,acLorD kBP.KaleilL1 Address 62..3Cenie (ti's L City lazy _Lica C-212 f0 phone* 207 341-ey y2_ <br />NELL LocatIon 0 Cy Ac <br />Assessor's <br /> Cross Street Zip q 527-° Parcells 0/Y--09- Ot27-- <br />Address "4CQ MAA•rt., 12o City laves' DE Zip g 4042- Piionesi #4.0/14 <br />GIS Coordinate e7 Y , Township 4/A) <br />WORK TO E PERFORMED: <br />ONEW WELL I BORING ( CPT, GEOPRO8E, HYDROPUNCH.±IAND-AUGER, OTHER') 'ISM BORING # - taki V <br />WELL a <br />COMMENTS . <br />4111mPnmm•••••••••M, <br />'Other: Grout Specifications' C.> <br /> <br />TYPE 9F WELL INST6LLA7fON rifE <br /> <br />MONITORING fl HOLLOW STEM <br /> <br />EXTRACTION Q AIR HAmMER/oRIvEN <br /> <br />o VAPOR a MUD ROTARY <br /> <br />a AIR SPARGE Q PUSH POINT <br /> <br />O SOIL BORING HAND AUGER <br /> <br />OTI-IER BOTHER <br />NOTE; <br />h eby cert <br />County Orel <br />y ,gned x <br />rInI Na <br />CONSTRUCTION SPeD;FICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS/ YES NO WELL CASING DIA. <br />CASING THICKNESS TYPE OF CASINO J STEEL a PvC OTHER. <br />DEPTH OF GROUT SEAL TREMiE TYPE TO BE USED. Ii AUGERS ()HOSE <br />GROUT SEAL PUMPED: DYes fl No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS' <br />APPROX BORING DEPTH fl BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED', ( if YES, list spacliica6ons here), <br />NGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />OR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />ared this application and that the work will be done in accordance with San Joaquin <br />ovulations, and all applicable California State Laws. <br />TioeiComanny M IIeáL_ Or OPEireflto.1.11 14.9sInsrA.) el( <br />s„Awira.cv.,04. <br />DEPAR MENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accaprod By <br />Grout Inspection By <br />Oestruction Inspection By <br />COMMENTS I CONDITIONS, <br />Dale <br />NIS <br />Date Issued <br />HAW Inspection By <br />c1( <br />ACCOUNTING ONLY. AID. FACIE <br />___t7,--- <br />PE CODES FEE INFO AMOUNT REMITTED CHECK SS REC'D BY DATE ' -3 = 5T# INVOICE <br />- <br />_ <br />OC) p ( / ' 7 ' _: ; II _ . _ _ ___ _.— <br />Jolt Pho <br />oote-S-70 -07 <br />SITE <br />MITIGATION <br />UNIT IV <br />Range 7E Sectlon 31 <br />(I DESTRUCTION (choose type below) 1S <br />I] OVER-BORE <br />2-PRESSURE GROUT \NJ <br />'COMMENTS: