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09/23/2004 11:07 2094663433 FIFTH FLOOR PAGE e2 <br /> �Ijg4L PERMIT APPLICATION FORM LOP & SITE <br /> (= SAN JOAQUIN COUNTY MITIGATION. <br /> O4 OCT I g Ah) ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT <br /> $ .Weber, Third Floor, Stockton, CA., 95202 <br /> IV <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County(or a permit t0 construct and/or Install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9.111 3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location-PO4 0�22C�C'/'S3rP-i / -Cross street Natty/N,�oer cJty �(' 'yY� zip 9$020 J Parcep'Fw%Cep-20300/ <br /> PROPERTYOvmerf o�"I' of$- -}ori Addresso">�� k).Wash�n110nS'1 . CilyS� Zlp�15kOI Phonoua09 9y(o 0146 <br /> C-97 Contractor TCG <br /> _Addess/1350fttenC¢rPukPl CityCe-&'/ zp95 aur}- 6 Phone#Q/(x85380/6 <br /> Consultant/Sub CntrThefTrCC-reAddrossi3//SwX/;,k)'r4W-4 cty5 aLica Phone#.2o(nbay93Y4 <br /> GIS Coordinates:x ,Y Township Range Section <br /> WORK TO 13E PERFORMED: <br /> )WEW WELL/BORING (C-Frrr�GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) p DESTRUCTION (choose type below) <br /> 'MOILBORING# �' �S hor)n,S,� aOVER-BORE. DIAMETER <br /> I WELL 0 o PRESSURE GROUT <br /> p"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> II MONITORING p HOLLOW STEM DIA OF BOREHOLE 0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> p EXTRACTION G AIR HAMMERIDRIVEN CASING THICKNESS_- TYPE OF CASING: C STEEL p PVC u OTHER: <br /> n VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE/PVC W <br /> U AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 13 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') \ 1 <br /> SOIL BORING aHAND AUGER GROLrr SPECIFICATIONSAW �S <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,fist sPWACatiOns in comment section) <br /> COMMENTS: <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. d" <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. ("v <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> 'T <br /> County Ordinances, Ryles an,4 Regulations,and all applicable California State Laws. <br /> Signed x ' Tille/Company l e o <br /> Print Name ��/``1.1IIVC Kntc.k4 Data /d 4�e4/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: r <br /> WORK PLAN DATED:_ C v l/t-w C2 C-13 <br /> Application Aeoepted BY ljkDate Issued_/G(/�J _ Area2 <br /> Grout Inspectlon By Datef 6 `L(n Final Inspection By Date_ <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: S Rte' t <br /> ACCOUNTING ONLY: AIDE! FAC1I <br /> PE CODES FEE IN AMOUNT REMRTED CHECK fF REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1 lL 1 /04tf SR# OOVOO V 3 <br /> C-57— WC`WAIVER— C-57 Letter of Authorization to sign permit`Encroachment doc_ 9/30/02 <br />