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09/23/2004 11:07 2094663433 FIFTH FLOOR PAGE 02 <br /> • • <br /> tWE4L PERMIT APPLICATION FORM LOP & SITE <br /> ' I SAN JOAQUIN COUNTY MITIGATON. <br /> O4 OCT 19 AM pE,NVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT I <br /> 97I�E-Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMR EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application IS hereby made to San Joaquin Coonty for a permit tOConsfrUCt and/or In51911 tlt®work described. This application is made in compliance with San <br /> Joaquin County Development Title,Cha ter 9.1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> f1 r�.I �7 r�C Cbz Assessors <br /> WELL Location�oY�o'h tAt��'rnry fhh crow StraetL-"IMoop , City Shock o., zip Qrj�O/ Paroel# /�0�0.300/ <br /> PROPERTY Owner Ort 6T STocC rO_h Address o'k�O� W .WnS li••gf'.,,S�City f n ZIp45ay/ Phone /& 20(a 6c/ <br /> C-57 Contractor['~ Address 10IPOO S <br /> Bi, 6re -� City Le rdro7�p c'(� ,'+A,idt��&.z$Phone#5/U(, ;��4p0 <br /> �`— <br /> Consultant/Sub DnrflvREIECC—ro" Address /o/SWICickr"t ✓ <br /> Citysea _Lc# Phene# <br /> aT <br /> GIs Coodlnatea:X Y Township Kongoao[o (ray r135ry <br /> Section <br /> WORK TO 13E PERFORMED: <br /> ANEW WELL/BORING (CPT,(3EOPROBE,HYDROPUNCH.HAND-AUGER,OTHER•) n DESTRUCTION (choose type below) <br /> D SOIL BORING# DOVER-BORE. DIAMETER <br /> aW ELL# �,•7 i 3 D PRESSURE GROUT <br /> "Other <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF W LL INSTALLATION TYPE CONSTRUCTION SPECI (CATIONS <br /> MONITORING ,�tOLLOW STEM DIA.OF BOREHOLE�� OM MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA' n" <br /> n EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_. TYPE OF CASING: D STEEL-4i PVC d OTHER: <br /> Q VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 3- TREMIE TYPE TO BE USED; D AUGERS n HOSE/PVC <br /> D AIR SPARGE/OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes n No (NOTE; MAXIMUM 7E-1FALL DEPTH1 15130') V <br /> Q BOIL BORING OHAND AUGER GROUT SPECI FICATIONS_l3�sn}eni)w a-I� QbDrf SgndP�Cr/RST ctMen�'binrT"a�W�Mrry C <br /> D OTHER:� OTHER APPROX BORING DEPTHo' D BOLTED TRAFFIC BOX orSTOVE PIPE / <br /> V <br /> CONDUCTOR CASING PROPOSED A/0 (if YES,Iist SP&dflWl0ns in comment seeh'on) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS o <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 Ordinances, Rules and RB ulat' ns,and all applicable California State Laws. <br /> r' <br /> Signed x _ Tiue/Company C-eo /0'4 ,4 <br /> PrintNome ILlh . IL -Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED:_ GV✓LW Q c t?� - yl py [_ c5 <br /> Application Accepted By. kA _ Date Issued `_( OLI r{ iL Area C <br /> Grout Inspectlon By Date (( L F'nal Inspection By P Date_-. <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: .-L ..tA-t • �/ — 7L k - jk/,/, <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST INVOICE <br /> 1"N,501 55 " 3730 4-11— to /? SR# oo <br /> C-57_ WC-=WAIVER— C-57 Letter of Authorization to sign permit_Encroochfnent doc_ 9/30/02 <br />