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Sep 09 03 04:05p Warle woodward <br />09/09/03 TtE 11:18 FAX 916 " 2900 URS <br />06/18/20g3 08:02 2094E .33 FIFTH FLOOR <br />1 -707 -374 -5677 p . 2 <br />WI Ii (3 <br />PAGE 04 <br />PE CODES <br />ACCOUNTING ONLY: <br />FEE INFO <br />-WAIVER_. C-57 C-57 Letter of Authorization to sign perrnif------Eosslooclin1en4doc-- <br />AIDS <br />AMOUNT REMITTED <br />, v 0 <br />CHECK <br />002.1 L16 z.Z. <br />Ffuril <br />REVD BY DATE <br />It IPeier ilf innfoicE <br />9/30/02 <br />HEAL Iii <br />''vtr WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY 0:3 SFp I 1 Pm 2: IRTIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PIERM1T EXPIRES I YEAR FROM DATE ISSUED <br />tippli cotton Is 'welly male lo Seri Joaquin Courtly Mr a permit to construct ancVor kisbil the work described. This aporicabon is made In compliarioatroth San <br />Ioaoulr) County D7tirgactrrin4T4t1:37,C!iltplarrsii171a543a.epnliectStaindarde at San Joaquin County ErnAnsnmental Health Department. <br />NELL Location Li I. jA4•rirtettut C' CL•vo I 14 S5Vg‘ilreet C-/Nei) city s c_ zp -So?- Parbogi:Irs <br />" <br />PROPERTY Owner Ci -T-g- c.,n,31".1.....r•Iss.Addrass tv. a lorboLa r-4-- City JrIckfe-- Zip 1S-kga Phone" •-•(1 9 q7-4-7 C3 9 <br />,.57 c ontractor LICA, dh..../ n1 I AddreasTc'. - city IN Virtu_ zpcffS-4-1LicsIliCinR-9 phone" -4-0 39 11—'13 CM <br />Consultant / Sub CM/. L•k- ri* -3-R- C?",1 L-/ Address CP*-4-4--"21 6 c• I.O bcy LurcZtc) Pcols TItu'll'313 Phone" '14 <br />015coordwrates-. X <br /> <br />, Township Range Secrion <br /> <br />, HYDROPUNCH, HAND-AUGER. OTHER') D DESTRUCTION (choose type below) <br />D OVER-BORE. DIAMETER <br />11 PRESSURE pRour <br />GROUT SPECIFICATIONS <br />C )",o ..+IIrtIV kArt.0.1 71:(7 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. Of BOREHOLE U MULTIPLE CASINGS I) MULTI-LEVEL WELL CASING <br />CASINO THICKNESS ec-3• Lk.) ;TYPE OF CASING: I] STEEL ,'PVC I] OTHER <br />DEPTH Of GROUT SEAL G. -4- TREPAIE TYPE TO BE USED: AKAUGERS 1 HOSE <br />GROUT SF-AL PUMPED: AVes 0 we (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFIC.ATIONS ACA-aZt- in-02mA- <br />APPROX. BORING DEPTH >MOLTED TRAFFIC BOA at STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES. list specific:Ilion! in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE RECtUIRED FOR INSPECTIONS. <br />I hereby certify that I have prepared this appliCation and that the work will be done In accordance With Sari Joaquin <br />County Ordinances, Rules and Regulations all aPplIcable California State Laws. <br />Tin:scorn pony 0 QAt-LAir <br />f..A.C)1.",)10,((iD <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, AD7IRES7: 2-0 (..12"."./V -e." , S+0 tic- "it") <br />WORK PLAN DATED: 5" 1 5— 0 <br />Application Accepted By UNjr1AAAr <br />Grout in:.pechon By <br />WORK TO BE PERFORMED', <br />(itNEW WELL 1 BORING (CPT. GEOPROSE <br />D SOIL BORING* <br />SWELL 0 <br />g 'Other <br />COMMENTS: \JS LILI1. <br />vik ego_ I Alr-Ak Ck_cr„tii <br />TYPE OF WELL, INSTA4LA rTaMIXEL <br />moNLTORING 19:HOLLOW STEM <br />EXTRAGTI ON a AIR HAMMEFUDRIVEN <br />VAPOR 11 MUD ROTARY <br />13 AIR SPARGE/ OZONE PUSH POINT IGP or CPT) <br />13 SOIL BORING ID HAND AUGER <br />OTHER, JJ OTHR <br />2 <br />Signed <br />Print Norm) Date <br />Destruction Irtspor-bon By <br />commENTS I cceltifTioas: <br />Date Issued `-1 fr Agin 6 21? <br />Date 1 24 SIC '5 Final Impaction BY i' Z-- 'S-10c6- Date ILIrt/IA,"• <br />Date