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03/26/2003 16:25 2094683e23 FIFTH FLOOR <br /> PAGE 02 <br /> IVELL PERMIT APPLICATION FORM <br /> SITE <br /> SAN JOAQUIN COUNTY TION <br /> MITIGA <br /> 04 FEB I I AN �_'M51�IRONMENTAL HEALTH DEPARTMENT (EHD) UNIT A <br /> 304 E. Weber, Third Floor, Stockton, CA_, 95202 <br /> (209) 468-3449 <br /> NQN-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 Cp unty Develo"pment Title,Chapter�9-1115.3 and the tandards of Sen Joaquin County Environmental Health Department. <br /> l'CnBE �o noP 'bea�.'JdnAN,; t 5141:ev. ts>ka wn %-,� R•(A& C� a R_s_0,4 Assessors <br /> WELL Location � Cross Street City ZIP Parcel#_ 1�\- 0 50-1 D <br /> Gla v. Ks�wd, 6 r,..`ni, S W cJb Seo c1c la v. <br /> PROPERTY w E LL O w N E& 15 N•W t cit Lorne. <br /> Owner PG IL E Address 3" g Clty Wa�,,,�} yrs~ jpT1598 Phone#C!� -Q�4-408 I <br /> Awv.•. :v.D.c Gav,&O, -cam '*Floo kan.ks6v,s( <br /> C-57 Contractor ky s _.� Xkmis F.�• Address P•0.6o x G F"7 City g zip C P. Lie#5 51�q 8 Phone#��I6� 7 44-I tF O <br /> - � <br /> Consultant l Sub Cntr CK-L t�A ',i\LL Address t55 GYo v d,PN e.- City Co k���dLic# Phone# Sto�58"1--I�j88 <br /> 1000 A+^: AY\�Ja cam„ a <br /> GIS Coordinates:X- Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> n NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") DESTRUCTION (choose type blow) <br /> U SOIL BORING# p OVER-BORE. DIAMETER iZ <br /> a WELL# U PRESSURE GROUT / <br /> GROUT SPECIFICATIONS l /L°iYlt 2 G�(6U <br /> 0`Other ` SAS <br /> COMMENTS; <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING U HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br /> MW-1 0 <br /> EXTRACTION U AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL W_rv1C []OTHER: <br /> U VAPOR p MUD ROTARY DEPTH OF GROUT SEAL " TREMIE TYPE TO BE USED: SAGGERS U HOSE <br /> p AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: d Yns q.11-o-(NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> n SOIL BORING U HAND AUGER GROUT SPECIFICATIONS /l/L=A7 C.c--�MC=N C-e- 64R(-7-� <br /> U OTHER.:_0 OTHER APPROX.BORING DEPTH 2 2 (--5 n BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED in/-O (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I hav repared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances R s and ations,and all applicable California State Laws. r�� , ,�, <br /> S ,/ <br /> igned x Title/Company /`�� ���.lJ c-t�-�r S% C( <br /> Print Name Date 02 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: I' �J� + <br /> Application Accepted Ey C, "V Date Issued K G <br /> ooArea <br /> Grout Inspection By ru U Date Final Inspection By Data <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> C-57_ WC -WAIVER_ C-57 Letter of Authori ti o sign permit—Encroachment doc _ 9/30/02 <br />