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on/-lut,2003 15 00 2094683433 FIFTH FL" PAGE 02 <br /> �EALW WELL: PERMIT APPLICATION FORM SITE <br /> �� ► �� SFRV4G� SAN JOAQUIN COUNTY MITIGATION <br /> o3!MAY2g P t 2=35 ENVIR'C�1VIwENTAL HEALTH DEPARTMENT(EHO) UN[TC�C, <br /> 304 E. Weber,Third Flt , Stockton, CA., 95202 <br /> 1209) 468-3449 <br /> hf_QM,,,fft1lM a-tE PER IM EXRIRES 4)MA.R FRONt OATf!SSU <br /> Apolicatron LS henhy made so San ;OaQuin County for a Parma to construct artdrar mstab the work desv+bed This appl"I;on m made tn comptlance wdh Sar <br /> Joaqul'iCounty Development Title Chapter 4-1115 3 and the Standards of San Jtsaqu+n County Fnv]roacprsssat»eeAA Department <br /> 1 r y Assessors e <br /> YELL Locattvn ZZ-5554 w ross Street C 1_ city t ZIP Parcels <br /> PROPER I T OwnerZIE dress Z S. ' yS+,A bZ Z�py"`^'�Pfianel6 <br /> C-STGonttActOr � 'w ~ ,4ddress-�.3�_L'- .Ec�� Cit}I ¢.�.- LICk-..�71� ,P�IOAad�� ' �- A" <br /> Cnrtsuftant15u4CnV AddrenaS4t40Uq +Q C�Ivrat 1+7r�irllcrY S _Phone* �t�s� StJ <br /> GAS LCD d�netes % Y � TGwns tp�t`�� C 5etisan <br /> MMS TO IEPERFOReAED <br /> NEW WELL f SORING(GPT GEOPROSE HYDROPUNCH RANO-AUGER,OTHER•) Il DESTRUCTION(cheese Vpe boowl <br /> �}SOIL BORINGS Il OVER SORE <br /> YI[ELL a. Q PRESSURE GROUT <br /> *Other _ _ Grout Speoftastvfts <br /> come.NTs <br /> TYPE OFINFILL INSTALLATION TYPE Cork TFIUCTI0N SPECIFICATIONS <br /> MONITORING `�HOLLOW STEM DIA OF BOREHOLE&t ,j MULTIPLE GAStpiGS?Il MULTI-LEVEL7 Q WELL CASING DIA e-L� <br /> Q FAcrRAC"EON AIR HAMMEWDRIVEN CAS)NIGTH CKNESS49&,5C> rYPi:-QFOAvNG p STEEL )t�'VC 4 OTHEFt <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL-r120' TtLhAtE TYPE TO BE USED 0 AUaeAS Q NOSF, <br /> 11AIR SPARGE f OZOne V PUSH POINT GROUT SEA4 PUMPED a Yes Up) (ROTE MAXIMUM FREE-PALL DEPTH IS 30') <br /> 0 SOS_BORING Q HAND AUGER GROUT SPF-CIFICATIONS <br /> a OTIiER. t7 OTHER. ___ APPROX BORING OEPTH 80LTECI TRAFFIC 80X ar O STOVE PIPE <br /> CQVd2UCTGR CAS*4?RQPOSEp� t rf tES 1r5t�pecrFcatans Rera} <br /> SCOMMENTS. <br /> NOTE OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL-THE UNIT IV IMSP -CTM 48 WOR"4S HOURS W ADVANCE FOFE ALL REQUIRED INSPECTIONS- <br /> I hereby cwtl,fy that 1 have prepared th* work wilt bie done in accordance with San Joagyn <br /> County Ordinances,Rul s aAd Regulations, and all applicable California State Laws <br /> Sgned x TIUefGGtnpany a~ y. ems+ rn thvr <br /> `-0 � <br /> m <br /> PrintNae 4- Oate _— <br /> EPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS <br /> WORK PLAN DATED: <br /> ADPItcatrun A�CGPted By44� Date tssuto © a� Areae <br /> Grout inspection By. Oe'e Fireat tnspedtan 0y flake <br /> Oesbvd> an 41&pec1wn By R7a e <br /> COMMENrs r CONDITtoris <br /> EACCOUNMNG ONLYODES FEE INFU AMOUNT R ED CHECK• R C'D Y GATE PERM17 J SERVICE REQUESTS 04Y010E <br /> C- WC -WA1VEQ/ C-5T I.etrter'of Avthor',z orr a sl F f Encronchment riot.__,_ 8129102 <br />