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07/25/2001 15 59 2094683433 FIFTH FLOOR PAGE 02 <br /> 10-24-2006 03 40FM FROM TO 15306766005 P.02 <br /> ! WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS•EHD) UNIT IV <br /> 304 E.Weber,Third Floor, Stockton, CA., 85202 <br /> (209) 468-3449 <br /> NON7R99UNOABLE PERMfT EXPtR1=S d YEAR FROM DATE ISSUED <br /> App4=tron rs hertby made to San Joaqurn County for a permit to constu and/or tmstatt tine work des=led T'hIm application is made.n compflanee w,th San <br /> JOaquln CoLmly Development Title,Ctlapter&1115.3 and dte Ssandards of San Joaquin County Public Hearth SeNtew,Ermrommental Heath Ornsson <br /> W>w11.Lvrat,on .S f ra a Cross Street 1 ,•ate Sf city .semvc �tp_p,T7_d��aro Y&prs <br /> PROPERTY Owner C,7' ��N -t aross„#2a5'_X7..1�1A6.-"V _City. 10,_ o zrPj,! _07Pnane 304 43�., X33 <br /> c-57 CorTtractgr v��W rst Q^r f�rr kddr ss r�D Ba3�E33L C4tYe1 11S 2JF>f4 _L1CQ I&ar Prlot,e� 7a7 c 7 - �C,�y <br /> Consultant y sub conimcinr�7G�1'�+cs •e�irSPadress 3�3o G�e!m.f fid- Crty�••�G�C__lea; Pi+rnei 6 � ae,� <br /> GES C erdinat2s,X Y 7ewnstap Range Serxcn <br /> WORK TQ 8E Pte__QRMEQ; <br /> 0 NEW WELL!80RTNG(CPT.GEOPRO5E EyYDROPUNCH HANO-AUGER O'T'HE=R') fl DEST'RUCTtON(choose type beJow) <br /> SOIL BORING# 13OVER-EaR5- <br /> W ELL# IJ ASSURE GROUT <br /> 'ca>�MOiliermTs, GMu[Specaflcauoms, — <br /> TYP> F WELL INSTALL 710N rept CCINSTREIL"Y30N SPECIFICAfEO.US <br /> gMONITORINGa FOLLOW STEM OTA OF BQRFWOLE S' MULTIPLE C,ASINGS1 fl YES AO WELL CASING DIA:_2, <br /> 13 WaRACTION jl AIR HAMMEMRWEN CASING THIClCNGSS�TYPF,OF CASING jI STEEL�/G 13 OTHER. <br /> Q VAPOR n MUD ROTARY D1=PTH OF GROUT 5 LSD TREMIrz TYPr:TO SE USEG. $AUG$R3 I7 HOa <br /> fl AIR SPARGE: a PUSH POINT GROUTSE AL PUMPED 19-Yas oqp (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> j!SOIL 8OR(NO (l HAND AUGER GROUT SPECiPICATIONS _ ,)CZ/ �ar�_.-A�t f <br /> o OT¢+E1 t• n OTHERAPPROX.EORINGs DEPTTf 4 80LTYD TRAFFIC BOX ar p STOVE PIPE <br /> CONDUCTOR CASING PROPQSE-:O��J (,f YES.Fst specaficattons here),_ <br /> NOTE` OFFSITE BOPJNGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNrr 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 be done in aCeardance vnnth San Joaquin <br /> County Ordinance R es and Regulations,and all applicable Califorrtf��a fState Laws. <br /> S'9 F _TsrllGpmpanY J T;[t! UP�jDriS7 / e l ��✓s�a/llhr � <br /> Print Name Ttf - <br /> DEQARTMEN1USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD ESS: <br /> waRK PLAN DATED; ?LryIAa o <br /> Apflticabon A=mted BY Gate Ensued Ares <br /> Gram Imspei:eori Ely 02r$ Crrtal trtspect on BY tura <br /> CestrpCGon IngpoeLon ep Date <br /> COMMENTS 100ND TIONS•_ <br /> PON <br /> ACCCUI`MNG ONLY AID-0 <br /> PH CODES FEE INFO AMOUNT FtEnnr=D CHECK-4 RECID SY DATE PFRMIT1 SERVICE REQUESTS INVOICE <br /> -3�o ( 32 69 -v- �9 r DO Z b 4"aC <br /> G-57 WC-WA1V2R _ C-57 better of Authartzotlon to sign permit Fncraachmetvt doc 9/27/00 <br /> TOTPL P 02 <br />