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iU/U8/ZIJU2 10: 41 2U''34b83433 FIFTH FLOOR PAGE 04 <br /> WELAERMIT APPLICATION F•M 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 /> Appllcalion is hereby made to San Joaquin County for a permit to construct and/or install the Work desalbed. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter g-1115.3 and the Standards of San Joaquin County Environmental Health Department, <br /> Assessors <br /> WELL Location I�aZO S�utb. Sc ttGJl,o�'Pn Cross StreetTGM[iri Lk br. city��, Xip ��_Z40 Parcel# 045-.300-iLl <br /> PROPERTYOWne&elald J. V arvlirl1ca S Address\32a3 e $GGl,mt��'m S1 City �,OCI� Zip r� 2 c�Phone(�/z6�G '24136 <br /> C-57 ContradorTrAer0h5>C FAV.«nAddressLZCQ tRc�,��til nrpj0 our# Phoneg( LV __?-33CO <br /> Consultant/Sub Cntr Address City Lit# Phone# <br /> GIS Coordinates:X ,Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> U NEW WELL!BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OYHER•) [I DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVERBORE. DIAMETER <br /> a WELL# 0 PRESSURE GROUT <br /> Other Se> Vr.�r ��,�� GROUT SPECIFICATIONS <br /> COMM Ts: �,l Vcr{ r� rtn , 2t IzZ t &144cm"i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLtiL, a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA_ MIA <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 14/64 TYPE OF CASING: 0 STEEL 0 PVC ODTHER <br /> H VAPOR a MUD ROTARY DEPTH OF GROUT SEAL7c I drPfh TREMIE TYPE TO BE USED: a AUGERS a HOSE W <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: nYes aNe (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) rf <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS PPCA{ Ce me rrl 0 <br /> AOTHER: a OTHER APPROX.BORING DEPTH 10 &e4 a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) ' <br /> COMMENTS: uJ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <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 Regula i s, nd all applicable California State Laws, <br /> Signed !company PrrciCd Dlr"r /T4C- <br /> d <br /> Print Name Date 1 Z)11'b16 L <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: / �/ Q <br /> 4ppiication Accepted By /__1�K�r•a-B'C�(_ Datelssued bZ OZ Area�U��6�LJ7�Dy <br /> 3rout Inspection By. h�k.-�+-e�_ - -Date I a b b2 Final Inspection By Date <br /> Jestructon Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTINGONLYc AID# - FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Ocl6 (o GlK /ZZs O SR# <br /> C-57 WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment clot_ 9/30/02 <br />