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' 01/09/2003 15 38 2094683433 FIFTH FLOOR PAGE 02 <br /> 12/27/2802 14:34 2094683433 NIrIH :-LUUK <br /> r <br /> I WELL PERMIT APPLICATION FORM SITE <br /> �1 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHO) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> INQ[u.4EFU1VDABLE I?ERMir MCPI1TP91 YFJ41i PRDID1 DA`fE l3SllED <br /> App1112tion Is hereby made to San dmupirt county fora parruit to comstruct and/or install the work described TPhIS applJOatrtan is made In compliance with San <br /> Joaqula Counly Davelopment Tile,Chapter 9.1115.3 and the Standards of Ssn,Joegmn County MmAronmetfl Health Depart runt <br />' Assesanr'6 <br /> "ELL Lac;Won2S�2Q� 'F'/Do U. s- <br /> r}Iaop- ro"Qr Cd,1 rfrf,.,. tjSAddres8 Zip ifkV Phone# <br />' C�67 Contractor, !i Addressi%� A _ Glty 7�G d.�t1c 3/&Sf -Fhona#9t3-3/'f-. 0� <br /> Censultdrt}t Sub Cr,br drassG .r�r Clty LrGif Phonei� yL -22.�='�7.zy <br /> 61S Ctwrdinates X Y TownshQ Range SeCUUT1 <br /> K>t d BEP FORl1tiED <br /> 1"cW WELL/80RJN43{CJ4.GEOPRORE,HYDROPUNCH.HAND-ANGER,OTHF-R*) 13 OESTRUC'RON(choose tae below) <br /> jl St71L BORWCa# Q G�Fi-BCJt�� <br /> P"SSURE GROUT <br /> I "'�5ther / � �� _ - - Grout SpeafiOsLens � <br /> COMMENTS � <br /> 'rYPE�WEL.L II48TALLAT101H TYPE CdNSTRUCTI.t?d$PP-G�A_-nON5 <br /> 1MOI�ItT0AW3 *, HOLLOW STENT D1A Of DC1 EHOLE 8" �f tj4' IPLE CASINGS1 Ij Y9$- NO WEU-QASING DL4 , <br /> Q EKMACTION 1]AIR HAMMERtORNEN CASING THICKNESS. TYPE OF CA.S NG 1]STEEL 0,PVC 13 OTHER,_ <br /> []VAPOR a MUD ROTARY DSM OP GROUT SEAI TREMIE TYPE Ta SE USED 11 AUGERS OSE <br /> aLp3 sPARGE 13 PUSH POINT GROUr-EAI,PUMPED p Yea No (NOTE MAXIM U rEE-I= DEPTH S 301 <br /> I qW'SbIL SORiNG Q HAND AUGER GROUT SPECIFICATIONS. , l <br /> 11 OTHER. n OTr]ER APPROX BORING DEATH QLTED TE FIC J34X or Q STOiIIE PIPE <br /> CONDUCTOR CASING PROPOSUD1 &_(ff YES,list sp=iicmUons here) <br /> I 'COMMENTS; i <br /> I <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. � <br /> ICALL.THE UNIT IV INSPECTOR 48 WOFWNCO HOURS IN A13VANCE FOR ALL REQUIRED INSPECTIOa. <br /> I hereby certify that I have prepared thiS applieatrar, and that the work Will be done In accordance with Sart Jt aquln <br /> I county Ordinan es, Rules and Regulations,and all applicable Califom:a State Jaws <br /> lk-d Al <br /> �gn9d x Trtle�CompanY <br /> �nnt Kayne Cato <br /> IDEPARTMENT.-USE ONLY <br /> 3ITi`MAP IN UNIT IV FILL,,ADDRESS: <br /> MORK PLAN DATED. <br /> %ppllcation A*mpted 6y ^ n 1A p V Date Issued elo Area <br />' grout fnSpectlan By Date,--- � —Final Insptchon By Dale <br /> )estrus lon Ens on By Date <br /> ;CMM ENT$1 CQNDITIOKS• <br /> I ACCOUNTING ONI-Y, AID# �arsl <br /> Pr cooaS FBe INFO AMOUNT REMMMD CHECK* RW"T 13A7E PSRMITI SERME REQUI~ST V INVOJCE <br /> l� 9 S Rig � <br />' �-57 We -WAIVER C-57 Letter of ALltho fi sign parrmtt Elzcroachment dar,,_ 1/25/02 <br />