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EMAP, 2-.2005 E 8:29AM 2094C"' '�R EARTH TECH YFIFTH FL.00R N0. 0108 P. 2PAGE 03 <br /> t] �``'' �rr-' L�1 <br /> REC�U�E ELL PERMIT APPLICATION FORM� � SITE <br /> a�t� 20G5 MITIGATIONS N JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> EW,FiONV- W KFS� NVIRONMENTAL HEALTH DIVISION (PHS-EHD UNIT N <br /> PERS�If/5Ft1J10E304 E.Welder, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> GWREPUNDAHLE PERMIT EMMES 1 YEAR 191ROM,QATE ISSUED <br /> APPr=tion is hereby made to-San Joaquin Countyfor a permit to COt 7S—Mmt and/or in9tali the work described. This appligOlatl Is made lienee with San <br /> Joaquin C=nW Development Tiift Chapter 9-1119;3 and the ftndards of San Joaquin Count Public Health Secvlces,l=nvlmnmErttal Health Division_ <br /> WELL Location l v�� C:Q��' - '. Assessors <br /> Cross Street 1 city &C K.tav+2ip., Parc4 <br /> PRaPERTYOwnerSf �liS <br /> A Address of 60 , r ict�Jd',City to i Phone# <br /> �w ,./ n <br /> 0-97 Cohtractor 1(�AP��'t, 3•I�G Add <br /> res?�Z.I)D �AtiVtG ik lr� C;tyPf -�dF� L'1 phane# 0- �JG7� <br /> Consultantf3ubCan&acaor(-70ND09'— &�AZ;ni-'-Address N1-W'65Tcity,�Lldl Phonee•Z ��•QxlB <br /> GIS Coordinates;x �r3�Ei S( .Y�[7(0 5 Tbq i STS, <br /> ^ �M—Rangeseeden <br /> WORK TOB EIWORM y A7 FVFV DEQ p& pgkke-..' <br /> Ejaf4EW WE"/17�ju <br /> gPRQ YDROP CH,HAND-AUGER,MER-) [I DESTRUCTION(dwow tyF,e below) <br /> SOIL NG# 0OVER-BORE <br /> 'other, WELL# Grout Spedliicadons• D PRESSURE GROUT <br /> COMMENTS. <br /> TYPE OF%WLL INSTALLATION*TYPE CONSTRU N Sp1=Ct191C 11ONS <br /> Q MONITORING Q HOLLOW 8'MM OLA.OF IIORRHOLE MULTIPLE CASINGS?AYES 17 NO WELLCASING DIA: <br /> d DCPRACTION 13 AIR HAMMERIORNSN CASING THICKNESS—_TYPE OF CASING; p STEEL Q PVO 11 OTHER; <br /> 13VAPOR b MUD ROTARY DEPTH OF GROUT 89AL TREM IE TYPE TO DE USED; t1 AUGERS Q HOSE <br /> [I AIR SPARGE d PUSH POINT GROUT SEAL.PUMPEO: d Yes p No (NOTE: MAXIMUM FREE-FALL,DEPTH IS 361) <br /> OIL.BORING 1]HAND AUGER GROUT SPEwCIFICATIONS., <br /> D OTHER: Q OTHER APPRO>C[BORING D9PTH (]BOLTED TRAFFIC SOX.or a STOVE PIPE <br /> CONDUCTOR CASING PROPQseo? (if YES,Fist spedfleatlons here <br /> •COMMENT : _�+ OIeJ� ��LL� 11.] QJti Nt�l (� lgAl <br /> l4 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin <br /> County Ordin ules and Regulations,and all applieahle California State laws. <br /> Signed x 'fids/Company <br /> Print Name ate J <br /> DEP -MENT USE ONLY <br /> SITE MAP 1N UNIT 1V FILE,ADDRESS: <br /> WORK PLAN DATED:____ <br /> Application Accepted Uy Date Issued Z--� Are <br /> Grout lnspectionBy Date FinalInspacdon Date S <br /> Destruction lnspec$on By Date <br /> CONEMENTS I CONDITIONS• <br /> ACCOUNTING?ONLY- AID# <br /> PE CODES E INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE RSQUEST 0 KPtVOICE <br /> of 6� tet. i .� 00 0 <br /> c=57 _—. W� 'RECEIVED TIME (APR, 29, ti 9:59AMthorizatiorttosign permit Encrotichrnent-do - 9/27/m <br />