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05/05/2004 09: 15 20946834'" FIFTH FLOOR PAGE 02 <br /> Il�RL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY <br /> .+11'r CF?f f�G MITIGATION <br /> d ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> n UNIT.IV <br /> 28 Pel 43q4SE, Weber, Third Floor, Stockton, OA.; 95202 <br /> (209) 488,3449 <br /> ID <br /> NON-REFUNDABLE PERMFr EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a perM4 to construct and/or install the work described. This ap n ePClia w'zh <br /> San Joaquin County Development TMJ Chapter 9.1115,3 and the Sia ards of San Joaquin Count/Environmental Health Department. <br /> _ Asea,ors 29{5o ulo <br /> WELL Location t" Croa9 8ite92 '1�� Cky �P <br /> Parcel# rC� �i <br /> PROPER <br /> Owner &1 ��Z'.Zi 4ddrEss- o q C}ty OC � Phone# `� �p 9 <br /> C-S7ContractorL � a address -Cb. C2 1 . Ctty fdYl �'1—niipLlct�6�w Pha� ZO <br /> Con,ulgnt/5u0 Cntr 1<1e- 1i1 G Lea Add,s9Zf!�z5 iA V1 L Cltv&i��s�u Pt one# �✓ <br /> GIS Coordinates_X Y Township Range <br /> Section <br /> WORK To 9E PGRFORMED: <br /> U NEW WELL l BORING iGP HYDROPUNCH.HMO-AUGER OTHER') 0 pEsa OV RTBOR ION S�tlose type below) <br /> n SOIL BORING# <br /> it <br /> DIAMETER LLIk PRESSURE GROUT <br /> 0 WE <br /> a'Other GROUT _VrCo,\, SUR;ZAp:e— <br /> SPECIFICATIONS i� G�lhAS Sf1 � <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING j]HOLLOW.STEM DIA OP BOREHOLE Q MULTIPLE CASINGS C MULTI-LEVEL WA <br /> WELL CASING OIA: <br /> C EXTRACTION 0 AIR HAMMER/DRP/1=N 'CASING THICKNESS TYPE OF CASING U STEEL' •(j PVC D OTHER: <br /> VAPOR 0 UD ROTARY DEPTH Q>+GROUT SEAL,_ _TREMIE TYPE TO 9E USEO; Q AUGERS Q He <br /> I Q AIR SPARGE/OZONE PUSH POINT(GP or CPT) GROUT SEUL PUMPED: []Yes Na <br /> OTE, MAXIMUM E-FALL DEPTH IS 301y <br /> SOIL BQRINO 0 HAND AUGER GROUT SPECIFICATIONS <br /> OTHER ov- OTHER_ APPROX,9ORING DEPTH �� r _—I]BOLTs�' IC SOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSE 1r (if YES.Ilat specifications in comment <br /> I hereb4cer�t hat I ave repared this application and that the work will be done in accordance wi h San Joaquin <br /> Countyce ule nd Regulations, and all applieshle Califa a State Laws. <br /> TRIe/Company r0 Ctl Print NaDate - <br /> DEPARTM NT USE ONLY' <br /> SITE MAP 1N UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> App(ig6on Accepted By- <br /> Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDR'IONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D Y DATE =-PERMIT f SERVICE REQUEST# INVOICE <br /> p 12-10 - SR 3 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc I. 9/30/02 <br /> 05/05/2004 WED 10: 10 [TX/RX NO 51351 Z002 <br />