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09/02/2005 08 20 2094683433 EHD PAGE 03 <br /> 0-24-2000 433=QOPM FROM a TO 157 <br /> Er-oc <br /> CEar WELL P IT APPS TION <br /> � SITE <br /> I• MM <br /> Atlr A 6 200, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT AT�C3N <br /> EIVVIRO WENS ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT!V <br /> PER1r/Sq Js rH 304 E. Weber,Third Floor, Stockton, CA., 95202 <br /> (209) 458-3449 C?5 � <br /> NON-Rt iJNPABLE,1?MFr EXP�Effl FRO MATE ISSY M <br /> Appr=brm is he-mby made to San Joaquin Ownt:r for a Permit to'Gomer d and/or mstall the went described 'flits applleatlon Is made in c4mpr=ce with San <br /> Joaquln Cpunty Dsveiopmafit Tule,Chapter 8-1115 3 and rhe Srandards of San Jaaquln County Pub5c Health ServlC 8,F-Wraremotal Health Dma1ion <br /> WsLL L0""*r lQS n , �k!1 Crass Stv"t c ly��z� � �D &°ta <br /> ?RaPeRrYown� �}EI�c I� Address D j �ty���p I"� nea�a5-gi+�-gam <br /> 0.67Cartlrad4r aLu loi�v �?�clarrss��SD J�orR:e _.c�I► r� 1 <br /> CansuftantIsub C=tradar S r rl�[ reSS �(!( is Cdy rJ BZ Phone#_. 7��0 6_ <br /> G13 COerda� W1a,k 555aY SORave . Seww <br /> WORK <br /> WF-W WELLI BOR1N CPT, I7PRO HYDRO N GER O Ek'} []DESTRUCTION tChovsa type below} <br /> 501E 90R1hFG Ci C�j- 1 E]OVER43ORE <br /> war l�WELL•�, ....---.«._____ CA9J C;pf'4" CPT=1 Q PRESSURE GROUT <br /> COMMENTS: dot SF�aifiCatia <br /> 1E OF thrFJt 1NnA_LLAMkj TYPE clous ittJCTIQN SPECIFICATIONS <br /> EI Mme+MFUNO a Houjow STl=M DIA Ot=9ORS 0L1=2--Ldd4-MULTtPLE CASINGS-'11 YES U NO WELL CASING DM,_ <br /> a MCRACTION 13AIR RAMMERIGRNVEN CASINO THICf(MESS TYPE OP CASING 11 STEEL U PNC U OTHER. <br /> ID VAPOR R MUD ROTARY, OEp-n i of cFRovr SEX 0!D!O TRf MIZ TYPE TO ZZ tisea. 0 AUGERS `VQ= �dP <br /> �IR SPARGE USH PolrtiiT GROUT I�uMPED ', Yes Na JNOTE: MAXIMUM FREE-FALL DEPTH 1S 30') , _ <br /> L EpFtING 0 HAND AUC4R GROUT SPEOMCATIONB Q �bv � _ <br /> 11 OTHER_ APPROX.BORING DEPTH j� 01-"rED TRAFFIC BOX or STOVE PIPE <br /> "COAd1HENTCONDUCTOR CASING PROPOSED nn(BYES,fist speaficaborm herer <br /> .�e <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PFRMIT'S. <br /> CALL THE UNIT IV INSPECTOR 48 WOWING HOURS MADVAMCE FOR ALI,REQUIRED INSPECTIONS <br /> II hereby certify that 1 have prepared this application and that the work will be done in accordarice with San JoagUin <br /> COLMV Ordihances I and 11toftions,and all applicable California State Laws. <br /> 016 x PC-or <br /> TftleJCompar,y t � <br /> Pr{nt N rcr� <br /> bEP TMENT USE ONIA <br /> SITE MAP IN UNIT IV FILE,ADDRESS: a ` Ld <br /> WIPRK PLAIN DATED' �rt <br /> AppllegrUoo Accepted By DarDaDe Issued <br /> Grout lr>$pectlan e ma!Inspeewn By <br /> DestruCd*n k1spe0bon By .• <br /> CW4dNlEN1''S I colltorrlaNs <br /> AfiCOUN nNG ONLY: AIM <br /> i <br /> OODE$ SEE WHO AMdRJ!`IT REI1liT't» CHECK RECD BY RATE PoWi r 1 SERVICE PMVESTS IANOIt;E <br /> 8' I <br /> Cr57 WC •WA1[VE=R—, C-57 Letter of AUtharo=fion to Sign pens It Encr4oachtrient doc 5127/00 <br /> TOTAL P,02 <br />