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.. <br /> 02/23/2001 10:05 209468343: FIFTH FLOOR PAGE 02 <br /> � v • , , � , ,. ,- <br /> ERMIT APPLICATIONI FORM SITE <br /> VVELL P MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION CA 95202, � ,�ot� <br /> 304 E.Weber,Third Floor, Stockton, D . <br /> (209) 468-3449 <br /> �s a Iicauon is made In compliance with San <br /> NON-REFUNDABLE PE MIT EXPIRES YE FROM DATE►SSU Environmental►-tealth Division. <br /> >pplicauon is hereby made to San Joaquin County for a permit to construct and/or install the work described. Th ce Assel=es 2."t,I- Z�{ <br /> baquin County peveloPment Tide.Chapter 8`1115.3 and the Standards of San Joaquin County Public Haatth Se Zceps gParcew _ T <br /> !4o I Elpty.14 Avtc Cross Street rr ity 3C$ <br /> NELL Locatlon� I,225 ,Phone# <br /> ` I A Address/gL� Q� ,`—City ,,.7a ? Y_ y.3op <br /> PROPERTY own 'ys�l LiNF _1�PhOne# <br /> s— S .Co R;,�,r Rd _City ,a t ziP — <br /> ttw�:= <br /> -57 Contractor C�AddSectionConsultant I SuRange <br /> Y ,Township <br /> GIS Coordinates:X belovr) <br /> D DESTRUCTION(choose type <br /> W K TO S PERFOR 1 (]OVER-BORE <br /> NEW WELL I BORING(CPT.GEOPROBE,HypROPUNCH,HAND•AUGER,OTHER'I 0 PRESSURE GROUT <br /> 0 SOIL BORING a —�— <br /> WELL 0 MW` .- _Grout Specifications: <br /> *Other: <br /> COMMENTS: <br /> INSTALLATION TYPE CONSTR CTION P 1;CATIONS NO W ELL CASING DIA: ! <br /> TYPE OFWELL MULTIPLE CASINGS. D YES �C D OTHER: <br /> MONITORING HOLLOW STEM DIA OF BOREHOLE��. <br /> e-L_1 yEV TYPE OF CASING: D STEELOSE <br /> Q EXTRACTION Q AIR HAMMERlpRIVEN CASING T}{ICKNESS TREMIE TYPE TO BE USED: D AUGERS <br /> Q MUD ROTARY DEPTH OF GROUT SEAL <br /> Q VAPOR GROUT SEAL PUMPED: Yes Q No (NOTE- MAXIUM FREE-FALL DEPTH IS 30') <br /> 0 AIR SPARGE D PUSH POINT er C.+� <br /> HAND AUGER GROUT SPECIFICATIONC s OL0 TED TRAFFIC BOX or STOVE PIPE <br /> Q SOIL BORING 0 <br /> OTHER__----- APPROX.BORING DEPTH_ -- (if YES,list specifications here): <br /> Q OTHER: CONDUCTOR CASING PROPOSED? <br /> "COMMENTS: <br /> NT PERMITS. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR E�oR C Eou RED INSPECTIONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVAWCEbe done in accordance with San Joaquin <br /> ill <br /> I hereby certify that 1 have prepared this application and that the work <br /> S til R <br /> ulations,and all applicable California State LaWS_ <br /> County Ordina <br /> TltlerCom W nto <br /> Signed x 00 Date <br /> Print Name n "J DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS. <br /> .."I <br /> WORK PLAN DATED' Area <br /> GAJ <br /> Date Issued <br /> Application Accepted By Dale <br /> Final Inspection BY'-" <br /> Grout Inspection B Y Date <br /> Deswcuon Inspection By <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: AIDA PERMIT f SERVICE REQUEST# INVOICE <br /> PE CODES FEE INFO AMOUNT REMRTED CHECK d RECD BY OATS <br /> Z <br /> �Sp 1 o 19/27/00 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to Sign permit Encroachment doc_ <br /> 2054663433 PAGE .002 <br />