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10/08/2002 10:47 2094683433 FIFTH FLOOR PAGE 04 <br /> WELAERMIT APPLICATION FAM 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 /> Appllcatlon is hereby made to San Joaquin County for a permit to construct and/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 /> Assessors <br /> WELL Location (3� Stl-tt� S Ct& APA4.6 'a Cross steetTaM0.rAck br. city Lei it xP ELCto Parcel# Qu- -300 -.3 <br /> 10 <br /> PROPERTY Owne&rAIA J 1/arvlirl )S S_Addressk3ZA S. Sc,Cr4 m $1 City f.g Zi{�S24JPhona({2 )(�M-ZL9S6 <br /> C-57ContMct0r'SrAe_1P GS ,C.EIV,rcnAddress_42c 1�cr1�4rr�. Cil ri Zp 10 Uc# PhoneA( DO14l— OO <br /> Consultant/Sub Cntr Address City Uc# Phone# <br /> GIS Coordinates:X ,Y .Township Range Section <br /> WORK TO BE PERFORMED, <br /> p NEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER•) R DESTRUCTION (choose type below) <br /> u SOIL BORING# a OVER-BORE DIAMETER <br /> a WELL# l7 PRESSURE GROUT <br /> Other Ss Ne.�r b,�r.n�$ _A GROUTSPECIFICAT0 S� <br /> COMM TS: Fior�t C�.p Rf{�Clrcd <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING p HOLLOW STEM DIA.OF 80REH0LE 24 0 MULTIPLE CASINGS H MULTI-LEVEL WELL CASING DIA: _ <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESSN�4A _. TYPE OF CASING: n STEEL 0 PVC DOTHER A144_ <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SI=ALTotett dtpl'lh TREMIE TYPE TO BE USED: p AUGERS U HOSE <br /> d AIR SPARGE/OZONE aPUSH POINT(GP or CPT)GROUT SEAL PUMPED: DYes ONo (NOTE: MAXIMUM FREE-FALL DEPTH IS301) _ <br /> 0 SOIL BORING O HAND AUGER GROUT SPECIFICATIONS NC-d{, Co mN of W <br /> )tOTHER:��_p OTHER APPROX.BORING DEPTH 10 (e eA ]BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: N <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. N <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, RUIEs and Reg do s,and all applicable California State LawsK. 11 <br /> Signed TitlJCompany Piny of U;f�GT�r' �`r2C, <br /> Print Name {" <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: / /J <br /> 4pplication Accepted By ld'K N�rP-1 Date Issued /U/Z S__/1),7 A,eaCCJ�� �l3/Qy <br /> 3rout Inspection By Date 1 L lrr b 2- Final Inspection By Date <br /> Destruction Inspection By Date <br /> :OMMENTS I CONDITIONS: <br /> ACCOUNTINGONLY: AID# - FAC# <br /> PE CODES FEE INFO AMOUNT REMITTE CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> mal 8yl d57- oY6 U 1 14�-' / oz SR# 003/ 410 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />