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10/13/2000 10:57 20946833 FIFTH FLOOR PAGE 02 <br /> %0111111, "111144 <br /> Mo �y[FTDELL PERMIT APPLICATION FORM SME <br /> MITIGATION <br /> 10 2000ENVIRONMENTAL T <br /> SAN JOAQUIN EA LDIVISION <br /> _DIVIS O PHS-EHD)SERVICES UNIT IV <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3448 <br /> Application is hereby ttiede io San Joaquin County fora to corn bW andforinstall 1ho work described. Thisapptloetlotl is made in oompilanea wlth$en <br /> Joaquin County Development Title,Chapter 111-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental H*Wth Division. <br /> t������ Assessor's <br /> LL <br /> WELoatlon 1825` N N�,i`w^T 9q Cross Strw Webomrrome City Ac Aypo zip'1S 20 Pww# O O%-03(8 <br /> PROPERTYOwnerw� Address P.o. (Sox 709 City HIM'"16+i O Zip9`S3%Pha►eM 9?S•Z=B-tStS <br /> C-57 Contractor Address Gty Zip Uc1t Phone# <br /> Consultant sub Contrscter T�k• BMt1iER. Pk!Ae1.d+ddre>;s b <br /> 4 1A t3 4 u+►. Wr coy Lon Ul 2121 M60 <br /> GIS <br /> GIS Coordinates:X z Y- ,Township_1 7 N Range ?E Sect;w 31 <br /> WORK TO BE EWMffJX- <br /> )KNEW WELL J BORING(CPT,GEOPROSE,HYOROPUNCH,RANO-AUGER,OTHER-) 0 DESTRUCTION(dwsa typo below) <br /> VSOIL BORING• G p OVERBORE <br /> 1 p PRESSURE GROUT <br /> •Ottltr: WELL e Grout a'peoihostions:,�►�+=1�r c��T <br /> COMMENTS: <br /> TYPE OF WELL INSTALLAT10N TYPE CONSTRUCTION SPECIFICATIONS <br /> ,'MONITORING DIA.OF 8011EI4OLE&5,_WAT1PLE CASINGS?Q YEs D NO WELL CASING <br /> 0 EXTRACTION D AIR MAMMEWDRIVEN CASING THICKNES,%SL%4 &J0 TYPE OF CASING: Q STEEL 8:PVC D OTHER: <br /> 0 VAPOR O 1JUD ROTARY DEPTH OF GROUT SEALS 454 TREMIE TYPE TO BE USM! 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE XPUSH POINT GROUT SEAL PUMPEOt 0 Yes pflo (NOTE: MAXIMUM FREE-FALL DEPTH IS 3(Y) <br /> 'SOIL BORING O HAND AUGER GROUT SPECIFICATIONS-- Tr 1"i sura- CtP.I' #t <br /> 0 OTHER:, n OTHER APPROX BORING OE PTH G O 0 BOLTED TRAFFIC BOX or (ISTOVE PIPE <br /> CONDUCTOR CASING PROPOSEOT (If YES,Het spectrIcetlons here <br /> •COMIIEff1Js <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 Out i have prepared this application and that the wont will be done in accordance with San Joaquin <br /> County nances, Rules and Reglulations,and all applicable California State Laws. <br /> SOW xTitleK.ompany"11 �_�►. 1 t P�/. �.jkatmc. <br /> Print Name 37�1*1, 1 . t31�Ae fl Date ///u /a o <br /> i� DEPARTMEN <br /> T US ONLY IL4.) <br /> SITE MAP IN UNIT III ffFILE, DDRESS: <br /> WORK PLAN DATED: <br /> Applfc 6 AcoWad By / Date Issued '� 2,01 Gam" Area <br /> Grout Inspection By pate Final Inspection By Osie <br /> Du ruadon buceclion By Date <br /> COMMENT't CONDITIONS: <br /> ACCOUNTING ONLY. AID# FArS <br /> PE CODES Fab INFO AMOUNT REMITTED CHECKS EC-D aY DATE PERMIT!SERVICE REQUEST i INVOICE <br /> 3 1 <br /> hC A UE&A W z0 AV ig US 6G <br /> G-57_ WC -WAIVER____ C-57 Letter of out ?�to sign permit_Encroachment doc_ 9/27/00 <br /> OCT-13-2000 FRI 10:58AM ID: PAGE'2 - <br />