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66/18/2002 09:23 2094663433 FIFTH FLOOR PAGE 03 <br /> Cx <br /> WELL PERMIT APPLICATION FORM SITE <br /> ' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> N '9 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202w II <br /> (209) 468-344$ Rut' I QOxt ' <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED 2j <br /> Application is hereby rhade to San Joaquin Cou*for a permtt to construct andlor Install the work dcacribed. This appkcolton Is made In comeAno:e vW San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San roaquln County Public Health Services,EnNrrnmental Health Olvidon. ' <br /> AssasWs <br /> WELL Location VPPCAL HArar C',ArA.. Cross Street 7nuY Rbva, City TIZACT p 4437it1, Pamei <br /> wwfv C,bE 9637$ 209 <br /> PROPERTYOrmer =aM1.4AT�ON rj..trw r AddresS 13ZO 7"4Y BLyk. Cky�AAcy Zip Plrone,9 d7S..OS03 <br /> idaa4ra..r Sm"T. W[GY 457 (",1 ' <br /> Gb7 Carttradar E+r>•eru«eM- 1•+c. Adrxess ).a. te;. 1604 City Swew...c..a ZJpt L4 UC01s"1441 Phmew,.377-N18 <br /> A:,paer h.cx6l ReN 3o4R, Sze Zao F.. eoAeaP t,,, (y 11,\\ <br /> Corr Rant l Sub Contractor Ert.rr(Lo,J,ge..rA r- Addrecc Q5 MaT,r€w< _dGYD- City FliLts LtierY tr7i1 Ptwnek�34.7cen <br /> (..tT, L6NC• <br /> GIS Cocrdinales:X S7.')raP7YS ,Y-111.4tSd4%4V6 . Tmmship_ OZS Range-± Section 23 ' <br /> WORK TO BE PERFORMED: <br /> U NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND•AUGER,OTHER") )(DESTRUCTION(choese type bewj <br /> U SOIL I BORING U OVERBORE <br /> SW ELL If Rw- (A nANM L,"T) (. RESSUREGROUT <br /> O� ' <br /> . Pf: rout Specihcaborm f- SAS SAND.3LvX>t Y' ori AIM7- CGr S� <br /> COMMENTS: Pari.£Aye +..ra oa-vY STe-Fc7"ED hi u✓@FL-Rorie bzrz +eA +r F"V,84V <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,y ' <br /> U MONITORING U HOLLOW STE1d DIA OF BOREHOLE 17-- MULTIPLE CASINGS7[]YES XHO W ELL CASING DIA: S <br /> 3 FErRACTION (I AIR HAMMBRIDRIVEN CASINGTHICKNESS TYPE OF CASING; U STEEL JIJIVC []OTHER; <br /> U VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPETO BE USED! H AUGERS U HOSE <br /> U AIR SPARGE N PUSH POINT GROUT SEAL PUMPED: n Yes p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) I <br /> U SOIL BORING o HAND AUGER GROUT SPECIFICATIONS, <br /> U OTHER: R OTHER APPROX.BORING DEPTH p BOLTED TRAFFIC BOX or li STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,Itstspecl5cabons here): I <br /> 'COMMENTS, Adc B'Sf Alt/1"AME. 7 NITa P>lwrp+ / WS3A iii ere Y-4-l-ooi 'Ate 7-jr-2a+2� <br /> (A'r7ACA V-b)i <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 /> 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,and all applicable California State Laws. I <br /> Signed,, �rFGX�- 7 Trile�Company i7iz+7eH`: �W6.Nc'7?t. AME 7n-�, <br /> Pdnl Name 12oY1�-r L_ Lfw r..•-_.a.vh Oafe 1.^S-PL - <br /> DEPARTMENT USE ONLY po I <br /> SITE MAP IN UNIT IV FILE,ADDRESS: '75 L1VRPICO ���Cky M1w�Lci�WVRPICO ���CU hW acB <br /> WORK PIAN DATED: 'Cn� <br /> Appikatien A:.cepted 9y Oate lswed <br /> Grout InSpatlon 6Y Data Final Inspection By Date- <br /> -Destruction Inspection By Date I <br /> COMMENTS I CONDITIONS: r y <br /> ACCOUNTING ONLY: AIDM <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK 11 REC'o BY DATE PERMIT I SERVICE REQUEST 4 INVOICE ` <br /> 240 ' S�5 6-12- 30/8Y ! <br /> C-5!� WC;WAIVER_ C-57 Letter of ADthorizntian to sign permit Encroachment do 9/27/00 <br />