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Mar-20-02 12:37P VIROr'c:X, INC. 510 F,98 7679 P.02 <br /> 03/20/2002 13:04 20945f,�3 FIFTH FLOOR rHac <br /> u.�• u.,.cur,/, ua taw•• t��yoo r.tr Ir' rLLkY1 `fit r'NIaG b3 <br /> Q�ZWELL PERMIT APPLICATION FORM SITE <br /> ON <br /> RZ SAN JOAQUIN COUNTY UNITOIV� <br /> ENVIRONMENTAL HATH DEPARTMENT(END) <br /> 30d E.Weber,Thilyd Floor, Stockton, CA., 95202 <br /> (209)468.2449 <br /> to M0EE Nb"L6 pR ROM RATE tBSUEU <br /> pplieanen is hcrwby mado to San Joaquin Goungr for a PWM''a tanatn rA mor in9fa11 Ma work described. TINA aanPPIWa47e madn in cornpGantx with-S" <br /> )3quin Counfy Developpment rWO,ChaPtw 9-1115-3 and the Sbndwds or San Joaquin count. &ioonmanW Heattrl DwamentAssess es <br /> IELL LOC 111 SI�f'- 4 5G7!.(• C�Sr111�Q��e Cross stleet br Y1?QlWf, City�r iLtLG <br /> ROPERrrowngr-7`Gleve 1,-,c Aadres=I0=0 sW C-yr-er%6 cty ir�i{a oa 2io`I722,�P SOS-j!'yq-8�b6 <br /> 57 contractor V i n?iL Addre9s 7I ro Ad a M S Ave CiN ?.Ip 97 ,�Licfe��5°f 2� Phettea S t 0- 676 <br /> nocukaat/sub Contndor IT ��P AddrosB <br /> 4-00.4 -&,-r Cl City 0,Acorz Isd�13�'!2Z-P►tone+�+°1z5-2�5-Z�u <br /> :15 Coordinates; <br /> Y ,Towndhlp IasnBe Q Section ---- <br /> X - <br /> gtt TO tt�PERFORMED DESTpucnoN(choose type boo ) <br /> NEy�I VJrt r I BORING(CPT,GEOPROSE.HYDROPUNCH.HAND..AUGER,MMElty 13 OVER,CORK <br /> (I SOIL BORING* Q PRESSURE GROUT <br /> tIV ELL* M W <br /> -P=t SperJHcalionr; <br /> ,OMMENTS' <br /> 7PE IE t WAS aTomTYP£ rrrsrrs�u'T SIECIRICATIOMS, •� <br /> (MoNfTORUIG HOLLOW STEAA OW OF SOREHOL�.MULTIFLE CASINGS?Q Y1=S �'N <br /> p WELL CASING OIA Z <br /> F�rrRACTiON D AIR HAMMERIORIVFJJ CAStNGTMicIQHESs 0.(}Lv TYPE oFCASiNG: 11 SYEEL roc 13 OT"ER' <br /> TREMIE TYFC YD SE USED. <br /> osa <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL V __ _ DR�H IS <br /> AIR SPARGE U PUSH Poon GROtIT SEAL PUMPED: U Yea �Vo (NOTE: MAXIMUM FREE-FALL 1 <br /> SOIL BORING O HAND AUGER GROUT SPECIFICAMON6; �6ptTE0 TRgt=FIC BOX a U STOVE PIPE <br /> 1 OTHER: 0 C1fiER APPNOX'BORING OCsP?kl <br /> GONPUrTOR CASING PROPOSED2 (ff YES,ha SPedf-i®Gons henry,' <br /> C0ININENT3c <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> GALL'TNE UNIT IV INSPECTOR 4E WORVEING"OURS IN ADVANCE FOR ALL R6CUIRED INSPECTIONS. <br /> hereby c*rtkFf that I have prepared this application and that the work will be done in aGoordanee with San Joaquin <br /> ;Ounty,Ordina Rules and Regulations,and all applicable C;.aIPRxnla State Lows. <br /> ;',aned x <br /> T'ilwCompanv 1 ,c��r�s-rc_�_ E-1 e, . <br /> 2 Sly, ti Pate 3 ab <br /> LQ <br /> ru,cName LY <br /> DEPAR US�ON <br /> iffE MAP IN UNIT 1V FILE,ADDRESS: <br /> WORK PLAN DATED' <br /> oar Issued "/At(d Z- �� l�� b <br /> Ikeatlon Aeoepted By- Qab <br /> rout Inspection By �� OsOe - Final inspegfon BY ----�^ <br /> I.Snarilen Inspection BY Date <br /> ;ptdMF_NTS J G�IWTN7N'.>s <br /> ACCOUNTINGONLY: AtD1l a�rn <br /> pQ cMES FEE imwo AMOUNT Rt741111 4 D CHECK d RECD 1311 DAVE PERNIIr 1 SERVICE REQUEST a< INVOICE <br /> C-57— WC___-WAIVER C-57 Letter of Authorization to sign permit_EncroacHmwt doc— <br /> (/25/02 <br /> 03/05/02 TIDE 09:39 ('TX/RX NO 5404) Ia003 <br />