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E)#tIIR4!()di NiWEL jPERMIT APPLICATION FORM SITE <br /> 1 . PER111T SAN JOAQUIN COUNTY MITIGATION <br /> NMENTAL-HEALTH DEPARTMENT(EHD) <br /> j l 03 JUL _g if ft-lWeber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 <br /> Application is hereby made b San Joaquin <br /> NOREFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> r CounN-ty for a permft to construct and/or Install the work described. This application is made in compliance with San <br /> J aquin County Development Title,Chapter 9-111 s.3 and the Standards of San Joaquin County Environmental Health Department <br /> IniC' 3550 S.IueffTg Rd <br /> Location Cross Street kwik 33 City UL'/n Q�tS 95j,j7 �sessor�, <br /> Q^., l r� ZIP ParceF# a(55--24—.R <br /> PROPERTY Ow -1I A OIAi AddressletrlD 111.'D44111hi rcir Tra 9-83b-Qio9 <br /> 2ts>e�,Hk �-0aie lr icrna{t f a?D N. city, ^ Zip r2-6bt{ Phone# <br /> C.57 Contractor Address E[L�Sfr ee`L LtlDodlaxd 85776 233 5�-(alo8-lsfzcf <br /> p��� 1' City Zip LiJi Phone# <br /> sultan Sub Cnb.G�Tix ca,"11.L`r.a.(d AddresP1:11 I,-,,foster St'(ZFL 5/ <br /> GIS Coardinates:X ) cryrylryGG6alc(a,.cl Ll� ptA Phonetr"D 3-�/Dp <br /> i_ <br /> Y ,Township 0✓ Range &E Section_ <br /> -WORK TO BE PERFORMED: <br /> `9'Nelfrhh'EI L BORIN (CPT.GEOPROSE HYDROPUNCH,HAND-AUGER, THER•) DESTRUCTION (choose type below) <br /> "O WELL# # T I5158-�lptS�'-I u�_ I 11OVER-BORE. DIAMETER <br /> _KREESSURE Ottte IP Trill tiro i rc � - �� IoDft 5 GROUT SPECIP CAGROU <br /> COMMS S: NS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS uD <br /> Q- <br /> 11 MONITORING [)HOLLOW STEM DI0.OF BOREHOLES c, UA (bY.s(r�tL(cC1r SDtI <br /> hDft Aj <br /> D t7CTRgCTION rn�R rr0 MULTIPLE CASINGS U MULTI-LEVEL WELL CASING�UI: <br /> Q AIR HAMMER/DRIVEN CASINGTHICKNESS MA <br /> i 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAW r .� E F CASING: 0 STEEL 0 PVC Q OTHER: 94 <br /> I]AIR SPI OZONE TYPE TO BE USED; n AUGERS _f IOSE <br /> 0 PUSH POINT(GP or CPT]GROUT SEAL PUMPED_- es u No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> I-7 %OILBORING [I HAND AUGER GROUT SPECIFICATIONS <br /> JI OTHER: 1;0T}{ER: lbnj!; APPROX BORING DEPTH f <br /> Drill 41 17DYt 5 Oft a CONDUCTOR CASING PROPOSED WO, U BOLTED Y TRAFFIC BOX or n STOVE PIPE <br /> COMMENTS; ,fa ( �aflf.� �, /d f_ D� (if YES,list specifiradons In comment section) <br /> NOTE: OFFSITE BORT GS RE UIRE ACCESS AGREEMENT OR ENCROACHMENT PERM► S. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> `J l-7 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> :ounty O tltanees,Rules and RJegulations,and all applicable California State Laws. <br /> Slgned d2Gf4-cX1 TOWCompany <br /> fl�Sti ' <br /> not N e Y✓,1f!/2 //h O7J _Date__�Z 71Q3 <br /> DEPARTMENT USE ONLY <br /> ATE MAP IN UNIT IV FILE,ADDRESS: <br /> .VORK PLAN DATED: (,.0&4t)a(.43 (y1 ip. 4L, D <br /> f. ppllwdon Accepted BY Date Issued 7�!7 D3 <br /> rout Inspection By Area L r,. /A )84J <br /> Dara Final Inspection By Date <br /> t Destruction inspection By Date <br /> OMMENTS/CONDITIONS: <br /> J I ACCOUNTING ONLY: AID# <br /> FAC# <br /> 'E CODES FEE INFO AMOUNT REMITTED CHECK S- REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> - / SR# S� <br /> ' C-57WC=WAIVER_ C-57 Letter of Authorization to Sighpermit-I P Encroachment clot_ 9/30/02 <br /> `J <br /> rl <br />