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01/03/2003 14:10 20946E 3 FIFTH FLOOR PAGE 02 <br /> fENVIRONMENTAL <br /> ELL PERMIT APPLICUrTION FORM SITE <br /> SANJOAQUIN CO MITIGATION <br /> HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E-Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 463 3449 <br /> NO_�-R<=FUNDABLE PERMIT FYPIRES 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. Thlc application is mads in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. ssors N A <br /> WELL Lontlon N�j,( E)f-IV - !/ tee I DFWJ Cross Street R�oNA2 r City S i OCKTa_L�P `�SZOZ Parcel# <br /> PROPERTY Own OF SToC�Tor-( Address�{2£✓" N, EL DoQ.�hDo SLCitySTocKror�1 up952oZPhon�#C2o9�937-83`f! <br /> C-67 Contractor CPSctNt>K T)(Li u-trAG Address 3b32 OM EC iRcc-F-7 Clty A Tip Ud�Tl7510 Phons#(9Ko��38-tllo9 <br /> Consultant/Sub Cntr�EO�f�N (nLC . Address3o P"SPI--Cl CityCoa-00,JA uc#7� 99 Phone#�Qtd 8S3^C9�tD <br /> R2� Dt2tv,E <br /> GIS Coordinates:X ,Y - ,Township N Range L� Section NDN E tVtn) <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') D R BOREµDIAMETEl a O%w <br /> Q SOIL BORING# a PRESSURE GROUT <br /> p <br /> WELL# GROUT SPECIFICATIONS N ee-)1PrT COMe-n <br /> COMMENTS <br /> *Other <br /> 4a)I �FiS rkrrD BE <br /> AV-F\LA 3�-��� t.a t T-1,4 <br /> t.-t L4,10 PVC <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCnON SPECIFICATIONS <br /> d MONITORING Q HOLLOW STEM DIA.OF BOREHOLE . , n MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> [(EXTRACTION d AIR HAMMERORIVEN CASING THICKNESS TYPE OF CASING: p STEEL p PVC Q OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO 9E USED: 0 AUGERS n HOSE <br /> D AIR SPARGE!OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED; q Y®s Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> [] <br /> OTHER:_O OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or o STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (f YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <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 Orlin noes,Rules an Regu tions, and all applicable Califomia State Laws. /l �` <br /> Signed x / TiticJCompany_ tL <br /> Print Name_ hal Tom} Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> e <br /> WORK PLAN DATED: ,2.I IV 0 <br /> 11 d-3 Area ` y <br /> Application Accepted By ` Date Issued 6 <br /> Grout Inspection By Date Final Inspection By Dat6 <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY j DATE PERMITrSERVICE REQUESTS INV0i0F <br /> 3 So C7cco SR# 3 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />