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03/24/2003 14:46 2094671118 AGE STOCKTON PAGE 02 <br /> Nw. <br /> f WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EMD) <br /> MAR 2, 4 2003 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> i-NVIRUNMENT HEALTH (209) 468-3449 <br /> PFRMITISERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> application 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 TIBe,Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department- <br /> n p -\ Assessor's <br /> NELL Location f Y`�I [�! J �� �"f 414 � Cross�Street ity S� �1 Zip�:�Parcel# t� <br /> PROPERTY Owner f1,� , G �`�31 Address / Jy- yC7� City 5 � Zip` ZDj Phon 93 7�3 7 I [� <br /> /+ !J �� o 5> qJr� u�'a(,' Mir Z�__ fv �}�r73 y <br /> ;-57 Contractc� r t ✓� Address City p 3LiC# Phon <br /> :onsultant/Sub Cntr AddressTJ Srlu CltyLicf+ J Phcne <br /> 315 Coordinates:X Y ,Township _Range Section <br /> NORK TO BE PERFORMED' <br /> NEW WELL/BORING(CPT—GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) L DESTRUCTION(choose type beloav) <br /> 0 SOIL BORING# OVER-BORE <br /> 0 WELL# g PRESSURE GROUT <br /> Other. Grout Specifications' <br /> :OMMENTS <br /> YPE OF WELL INSTALLATION'YPE CONSTRUCTION SPECIFICATIONS �nq� <br /> I MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE- IPLE CASINGS?g NIULTI-LEVEL?0 WELL CASING DIA/"' ' <br /> EXTRACTION 0 AIR NAMMER/DRIVEN CASING THICKNESS A114- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER:_` <br /> I VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL f � TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> I AIR SPARGE/Ozone,2-5�1­1SFi POINT GROUT SEAL PUMPED:x-Yes 0 No, ,(NOT : MAXIMUM FREE-FALL DEPTH IS 30') <br /> }-SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: i <br /> I OTHER: B OTHER APPROX.BORING DEPTH /--;;E7 0 BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASING PROP05ED7o�� (if YES,list specifications here): <br /> COMMENTS: T - 450 3 �� F Hfn <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> '.ounty Ordinances, Rue nd Regulations, and all applicable California State Laws, <br /> iigned x wgtZ J Title/Company 0 za'Ian / <br /> 2rint Name U/// U 7TC/ Date <br /> DEPARTMENT USE ONLY <br /> 31TE MAP IN UNIT IV FILE, ADDRESS: -�4� A), <br /> MORK PLAN DATED: <br /> application Accepted By Oats Issued Z a 22 Area <br /> 3rout Inspection By Date l Final Inspection By Date <br /> )estructlon Inspection By Date <br /> :OMMENTS/CONDRIONS: <br /> ACCOUNTING ONLY: AID# -T <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REG'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 350 ! $9� 3 2 03 331 1S <br /> -57 WCC WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc 8/29/02 <br />