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10/08/2002 10:47 2094683433 FIFTH FLOOR PAGE 04 <br /> • <br /> WELAERMIT APPLICATION FORM 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 /> Appllmdon is hereby made to San Joaquin County for a perm@ to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County DevelopmentTitle,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> Assessors <br /> WELL Location 11 Z9- 13cil­- S SC.clGre/rlo SI . Cross SlreetTanarn tlC. Ur. Clry IJ`-CA; Zip 9s490 Parcel# OL(S 29U�a£S <br /> PROPERTYo merN i SCA r 2 M _Addressl)2`j S. S-icti mcl)4 . City LDd Zip%SZ - Phone# <br /> C-57 Contractor�L01tiSL. FnUrr. Address; Cb `bJ. ityj,5An5,4K ZIpjpc1I40Lic# Phone#L��if 7'33 <br /> Consultant/Sub CntrTRC. ­Address$692. Cr,N.rnerc.al 6'ratyCon r Lic# Phone#C4Z5�$$"120` <br /> GIS Coordinates:X ,Y.Township Range Section <br /> WORKTO BE PERFORMED; <br /> )rNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) p DESTRUCTION (choose type bekrn) <br /> I]SOIL BORING# U OVERBORE. DIAMETER <br /> a WELL 11 PRESSURE GROUT <br /> •Otherur QOr 6r�r nSS GROUT SPECIFIC TI NSyrt) <br /> COMMENTS: � Yc13or, <br /> Y�1 ,Q_ \�2 q �[S ��1+ 14tfC.C�P <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING tl HOLLOW STEM DIA.OF BOREHOLE;,_- 1]MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA 13/h <br /> p EXTRACTION XAIR HAMMERIDRIVEN CASING THICKNESS A►IP TYPE OF CASING: n STEEL p PVC d OTHER: WA <br /> a VAPOR 1]MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS 11 HOSE <br /> a AIR SPARGE/OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 11 Yes WNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING aHAND AUGER GROUT SPECIFICATIONS f1PLlA/ v.mvr)4 <br /> )KOTHER:�IIbr 1]OTHER APPROX.BORING DEPTH (0 t t EL 0 BOLTED TRAFFIC BOX or p STOVE PIPE ` <br /> CONDUCTOR CASING PROPOSED (it YES,list specifications in comment section) N <br /> COMMENTS: <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 Regulations, <br /> and all applicable California State Laws, y / J <br /> Signed x?�1�1� /"Gc-GIiLTl Title/Company ,2LQ e-c l ire-C f6f- /T� R' <br /> Print Name bc-2h E" it Date infia/D'L rZ�. <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: qq �/ / <br /> Application Accepted BY Ad'�e of Date Issued 1012-S/02 Area�U o``OO� <br /> 3rout Inspection By / \ Date 1'L 6 b1 Final Inspection By Date <br /> Destruction Inspection By Date <br /> :OMMENTS/CONDITIONS: <br /> ACCOUNTINGONLY: AID# - FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT V SERVICE REQUEST# INVOICE <br /> SR# 00316SY <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />