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WELVPERNUT APPLICATION 04" SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES T� <br /> ENVIRONMENTAL HEALTH DMSION (PHS-EH N <br /> 304 E.Weber Third Floor, Stockton, CA., 952 <br /> (209) 488-3449 r JAN 2 2 2002 <br /> E T HEALTH <br /> App>btion is I�er�uredo to San Joaquin C=m*rar a permit to cDrmftm t andW IndW Fhe work I m - 1, . Thlt wih am <br /> ,aq Coiuty Devakpmm Tifie.Chaptff 9-4115.3 and the Sbmhbts d SM Joaquin C W ty Pubk HeGM Ad's <br /> WELL Uxaft n :562 &-A1,ms lma „ .._�, t`4 i rayr oe��.c ... ��.— �sb-ilo-�3 <br /> MURnM Y owner Ili►�4vvvr Addraes 1110 "L&Ift I BJP_ter <br /> 0 f� ALX pztys `f'r�rb ,fT ud� �7 Z. Q6 .�•9s�'8 <br /> caesulbuaelsubcar*2dor uar v�cP OAddnsss ` T_75c�►so"u ©y�'� 7t `�1F <br /> -.--�-_ <br /> GI'Coordkmbm X .Y Township Range Secdm . <br /> EW WELL/SORING(cpT.GEGPRoem HYDRoPuNcH,HAND-AUGER.Qom"} Q DESTRUCTION(dmm type bobw) <br /> a <br /> # p ESSURE GROUT <br /> `Qllwr: Grout Spedllrailnrrs: <br /> MOMENTS: <br /> TYR OF 11100-1. mv-4&am ]f <br /> )<MOM=1R&IG OLLOW STEM OFA.OF®Qi MgCLE__%,a:i�MULTIPLE CASINGS?11 YES WE-L CA 1NG DW:2 <br /> a SCTRACTION 11 AIR HAMMERIDRIVEN CASING THK204M. vtf <br /> PE OF CASING: p kwVC a OTHm <br /> ll VAPOR Q MUD wrmy DEPTH OF GROUT TRSW TYPE TO 8E US®: � 0 HOSE <br /> [!AIR SPARGE 1]PUSH POINT GROUT SEAT.PUMP®: Q Ye (NOTE: UN I- -FA11 DEPTH IS 301 <br /> 11 SOIL BORING ]]HAW]AUGER GROUT SPECIPFCAi1oN5: I- las, H.04) <br /> ll OTS OTHER APPROX.MUNG DEPTH• 2-5 SOLTED TRAFFIC BOX at 13 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?-,&L(EYES.itst Vedba*m herak <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT N INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUMED INSPECTIONS. <br /> I hweby cardfy that I have Prepared this appikadon and that the work will be done in accordance with Saul Joaquin <br /> Cowft Off, Rules and eguhdions,and all applicable California State Laws. <br /> Skpmd x ` Spey j �-e �3 S Pon <br /> `' <br /> DEPARTMENT USE ONLY <br /> SITE MAP 0 UNIT IV F'R.E,ADS' <br /> WORK PLAN DAIMM: 0-7 <br /> App/rs�n AcmpIod Ey41/ Dale Isaued 2©v Z Arecr�� <br /> Grout Mrspedlon <br /> Da�dian By <br /> / <br /> ACCOUNMG ONLY: AID# <br /> PE CODES IUPC ANKRMT REIN!I ED # PER w/mtvm PASTA NV010E <br /> fill- so d) II <br /> 2L I <br /> C-5T WC -WAIVER C-57.Latter of Auth a rt c#oc 9/Z7/0� <br />