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Z 00 006l6L9 916 XVd OC:CT NOW CO/OC/90 <br />COMMENTS / CONDITIONsi <br />ACCOUNTING ONLY: <br />PE CODES <br />C-57 WC \ -WAIVER C-57 Leifer of Authorization to sign perrni <br />\'e.,51-1ta <br />PERMIT I SERVICE <br />SR# 00, 5/ <br />INVOICE <br />9/30/02 Encroachntent docw/41 <br />Jun 30 03 01:43p Wayne woodward 1 -707-374-5677 <br />P - 2 <br />ORIGINAL PA6E 86/10/28E44 <br />, , ! <br />04#3 - FIFTH FLOOR <br />03 JUL - 1 AM 10: 16 <br />Au) 1 1 , (21 t3 WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />td017 2 56eA- <br />1 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />flON-R DAB PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />kppilesition ic hereby made to Sen Joaquin County for a peernit to construct andior install She work doaeribad. Thic application is mado In compliance With San <br />loaouln County Dc4elopment Title, Chaplet' 9-111s.r Ine Standards ECIDa <br />0_51 Joaquin County Environmental Health Depanment. <br />Var PIP- ,.. Aciataisors <br />NELL Locztleso 1 ( c. E• YO SC- ^,-, I i'e- A N-i 2 • class Street -1-19 9 City VOL TI-4-C--4ex Zip 9 573 4,-, palms* <br />'ROPERTY Owner A f-Ln ..__.1“::,•-ctfei c.frioxig,,.., 4 Cz4e.---rz;,a C)r- • city (....o. 7 et iiru... 743 13136-P.3 phona 1R-S "D 9 9 - 3191 <br />G-4-7 Contract Lie° J‘..-1 .°Yit.kk'n, Address P.(.)' Vtr"Js .73 CA CS° '7")CityIlrGut / I tIr•-• Zip 94 5.-Liclt-3-1(1019 PhorieP -1-0-1.- 3 -4-L1 -(430 <br />001 4 1.w.P3(A" <br />Consultant / Sob Cntr,. \'-A. VS Q'vP (4."te,i)C4ddreas -a-rtE4 G asi-Gag'41 016 S c,r-:. I _Id. ?G- 'WO phone( qIC 6 -i-1 --,?---3 g _7 <br />ScatIon <br />SS Coordinates- Y Y Flange , TownsMp <br />WORK TO DE.PERFOtad7P. <br />NNEW WELL I BORING (CPT, GEOPROI3E. HYDROPLINCti. HAND-AUGER. OTHER') <br />fl SOIL BORING* <br />1/WELL L.1 -1 I , I . 41' <br />'other <br />fl DESTRUCTION (cnoose type below) <br />1) OVER-BORE. DIAMETER <br />PRESSU RE GROUT <br />GROUT srtGIFICATIONS <br />••••1 <br />cke.\ COMMENTS: <br /> <br />rtrE OP WELL <br />AMONiTORING <br />a ExTRAcTioN <br />!IISTALL.3TKIN TYPE <br />"XtiOLLOW STEM <br />(1 AIR HAMMER/DRIVEN <br />El VAPOR 0 MUD ROTARY <br />it AIR SPARGE/ OZONE a PUSH POINT (GP or CPT) GROUT SEAL PUMPED: NOTE: MAXIMUJIZREE-FALL DEPTH IS 301 <br />11 SOIL BORING 1:1 HAND AUGER " GROUT SPECIFICATIONS rt-a.f.9.- e .O Kr- L...4 '' 6 eivtii ,t'i kJ <br />a OTHER: pi OTFIER APPROX. DORING DEPTH -3576C.) " ',MOLTED TRAFFIC BOX or 13 STOVE PIPE <br />CONDUCTOR CASING PROPoSED (i1 YES. list specifications In comment section) <br />COMMENTS:_ NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />p inances, Rules and Regulations, and all applicable California State Laws, <br />Print Nerne_CC216JcC —/ E 1A-A )0 L.) fe <br />DEPARTMENT USE oa....y <br />SITE MAP IN war IV FILE, ADDRESS: /7// <br />INORK PLAN DATED: <br />SITE <br />INMGATION <br />UNIT IV ON <br />attad 7-° <br />cONSTRUCTION SPECIFIATIONS I <br />DIA. OF BOREHOLE 4?.75 I) MULTIPLE CASINGS [)MULTI-LEVEL WELL CASING DIA; <br />CASING THICKNESS Tya OF CASING: U STEEL AFTIC tI OTHER. <br />1 <br />DEPTH OF GROUT BEAL I, -4-4.4. — ,Si TREMIE TYPE TO BE USED: ItAUGERS OraHOSE <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County 0 <br />Signed Tgle/Cornpany ES/De A)/ <br />Date <br />kl uo wf9-(P- D / <br />coto <br /> <br />Date Issued 7-tc -03 <br />Final inspection By Dais Date <br />Date <br /> <br />Application Acceplacl By <br />Grout Inspoctorl By <br /> <br />Destruction Insper.lion By