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01/30/2001 10:21 10'34bbJQ33 I-11- I rLUUK rout by <br /> WELL PERMIT APPLICATION FOOM <br /> SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468.3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct end/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessnr'- <br /> WEL I.Locallon Lf D Alo2ni 6jal q STae-fr Cross Street E L-M ST cityn LGD -ZIP L1ZParcel#, OY3_O> 5 LI Z <br /> PROPERTY Owner M-P T,4WSTMOLS Address 7-453 2 2 �CKT'Gn( Zlp9S?07 Phone#(209J'+77-3833 <br /> C-57 Contractor/Z0,,,tEni-1-igc, Address 2 110 ADA1151411104LtC City5i%&,4t4Ar oZip cj�LIc#70592 Phone#(S(0)S(6u-7(,Ifo <br /> d /Sub Contradnr EZC-PCT'1SDl/}RON/LL(i Address 5300&-pmc bn l <br /> onsuitCity-56i,�6FiCLZ LicN Phone#_(h6,1)83i ?oy <br /> GIS Coordinate&;X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> X,NEW WELL/BORING(CPT,GEOPROBE,HYD NCH,HD-AUGE TH R'� o DESTRUCTION(choose type below) <br /> ZN - { Q,jSOIL BORING# <br /> TO 0 OVER-BORE <br /> 11 WELT.# 0 PRESSURE GROUT <br /> 'Other: Grout Specification,,_i3t . n,Ji?E 1,CLLM TT, SF-T.. Ate'-4WL <br /> COMMENTS: r-or_(-oL,)e-P Lb's/ rle-�r ccM4?W (WI 10 5%��rMn1/TpowDd2Af*t--1)) 7v G(Loun1D Sy(1�- ✓iH 77ZCAI/C11MS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_Z!' MULTIPLE CASINGS?0 YES ANO WELL CASING DIA <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL 13PVC n OTHER: <br /> U VAPOR 17 MUD ROTARY DEPTH OF GROUT SEAL fes. 50 r� TREMIE TYPE TO BE USED: pus p <br /> HOSE <br /> 0 AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: 0,Ye3 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: n (-MITW WjrH 5�, �7NRpq17 PCi,,6 IZ <br /> 11 OTHER: a OTHER APPROX-BORING DEPTH ZO f r-- (�: Il BOLTED TRAPFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? A(o _(if YES,list specifications here)- <br /> 'COMMENTS:((LE CT- f>LtSt{ 51(L 0,�iz us , <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Ordinances, les and Regulations,and all applicable California State Laws. <br /> Signed 1)2 TitlelCompany S Lo Ci�cc�prs� - EzC (2c-r�n- W7.11V LSC <br /> Print Name �K C Date 1 3Z1�O2 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: J / <br /> Applicatlon Accepted By Date Issued /0%�oz_ Area(tJk,--dC <br /> Grout Inspection By � Date /0 2 Final Inspection By Date / <br /> Destructlon Inspection By Date <br /> COMMENTS/CONDITIONS; U <br /> ACCOUNTING ONLY. AID# <br /> r�r•N <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUESTill INVOICE <br /> AZ SR# Oo <br /> C-57' WC=WAIVER_ C-57 Letter of Authorization to sign permit_.,_Encroachment doc_ 1/25/02 <br /> n03/ U?& <br />