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04/22/2004 10:28 209467" AGE STOCKTON PAGE 02/02 <br /> 04/22/2004 08:56 2094683433 FIFTH FLOOR -ILAE 'CO P Y <br /> WELL PERMIT APPLICATION FORM <br /> ME <br /> 2 2Q <br /> APR j 4 SAN JOAQUIN COUNTY MITIGATION' <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHE)) 'A7lON <br /> N E-RliIVivjE-P11 304 E.Weber, Third Floor,Stockton, CA., 95202 UNIT IV <br /> �' fiMITISERIII Srli . <br /> (209) 468-3449 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATI=ISBU£D �� �35 <br /> Application is horeby made to San Joaquin Countyfcr a perrnd to construct andlor i M11 the work described. This dpplicatJon Is made In cot tpl�ncb v ith gen <br /> Joaquin GountY Devekpment f els•Chapter 9-1 y 75.3 and the Standards of San JoaquFn County environmental Ha dth c2l]on s m <br /> tryEtU C.ocatlon�9 �U r r Assessors c� <br /> /sex Crass Stregt bRWooD CiiyZ p{�?2yPrrrce,>x� <br /> Ps20PI�R <br /> Address <br /> G5 `0.1 <br /> Otivner I / <br /> CST Contractor fl }} F� <br /> tldrr os4L=LJ_ City Zip�r`_�Ic# <br /> C0nsuftarrdISubCntr 64VAddres '�� Ity ick Phone# <br /> GIS CoOrdlltato9:X Y Townehlp —_- Raanggee ° Section <br /> tqMZO-0P,kNEW WELL/BORING (CPT,GEOPROSF,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTF:UCTION (choose tyle below) <br /> 0 5014 BORINQ ���� <br /> 0 WELL#__V Nr b •• 0 OVER-801 I_, DIAMETER_` <br /> U*Other --�4— A'I�`l:3 p PRESSUIee OPCUT . <br /> COMMENTS- r' GROUT SPECIFICATIONS <br /> U MO rF N�� INSTALIA71_ON TVP_ ON TRUCTION SP T NS / Cm 7 Q/1S <br /> U MONITORING �410LLOW 51-EZyt DIA.OF 6OREHOLE� T1pLE CASINGS 141UL-I-LEVER WELL CASIt IG Dln: <br /> 11 EXTRACTION ;j A1,7 HMM JA p oizzjVCh! CASING THICKNLGS I YP OF CASING: 0.-TEEL ,S'PVC p OTF ER: <br /> ,*VAPOR 0 MUD ROTARY DEPTH OF GROUT SEA <br /> LTREMIE TYPE TO BE U5E0: <br /> QAUGSRS QH09E <br /> a AIR SPAROFf OZONE Q PUSH POINT(GP OrCPT)GROUT SEAL PUMPED: ,Qh'es a Ngo//(-NOT :MAXIMUM FREE-FALL DEPTH IS 30') <br /> D 801E BORING p HAND AUGER GROUT SPECIFICATIONS L►2��7� <br /> Q OYHEIrt p OTHER APPROX,BORING DEPTH fJ.BOLTEp'"R4FFIC BOX or q Sl JV!?PIPE <br /> I <br /> 'ICONQUCTOR CASI G PROPOSED (If YE!;,list sPecifirations in cor Imant acclion) <br /> COMMENTS: 7+ U (����S — /h �JI/�NOTEPFS1T BORINGS REQUIF2E ACCESS A ED <br /> R ENCROACHMENT PERMITS. <br /> 48 WORKING HQURS NOTICE REQUIRED FOR INSPECTION:.- <br /> 1 hereby certify that.I ha prepared this application and that the work will be done In accordance with San Joequin <br /> County 0 ���� � gulati0ns,a all a pllcable California Stats ws. <br /> Slgrad x � <br /> TitlelCompan � <br /> y '�! <br /> Print Name <br /> DEPARTMENT USE ONLY D> 2� <br /> SITE MAP IN ONIT IV FILE,ADDRESS:7-21 Q A/ JY <br /> WORK PLAN DATED: /4/ <br /> APPnCation AccepCEd 3y Date Isvied <br /> Grout Inspec5on By Ara@ <br /> � _,Final Inspection By D� <br /> Destruction Inspection By Data <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FACx <br /> ZFFGDES FEE INFO AMOUNT RMTTED CHECK# REC'D OY DATE PERMIT!9EP:VICE REQUMGT 0 I�VOICE <br /> C-57 WC,=WAIVED— _ C-57 Letter of Authorization to sign permit_Emroachment doc, 9/30/02 <br />