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MAY-07-2003 14:45 URS CORPORATION 15108743268 P.04i13 <br /> TE <br /> WELL PERMIT APPLICATION FORM IMITIGATION <br /> SAN JOAQUIN COUNTY UNIT N <br /> FENV1RaNMENSAL HEALTH <br /> S ockton CAT95202DEPARTMEN } <br /> 304 E.Weber, 7hl(2Q9) 4BB-3449 <br /> 0 F NDA8LEPERMITEXP <br /> 1 p ATE ISSUED <br /> made to Sen Jo9quin County for a Pe—n to wnstrucrend�ar Instal Ltie Work described. This aPplit epa is mach in ppmplfgnne w en <br /> APptication is hereby AsseSsues <br /> Joaquin CoUnty Drs�elopment 7'rt1e,Chapter 9yRUio Sand the Standards Of Ssn Joaquin CoC`�ry 5�a C.KTOr�I Health q�3 e arrel# <br /> 161- 43U-a2. <br /> 3�0 IJ�Y�Satt1`IT C Cross Strenc 4 4 4l8`� <br /> YYELL l oaaUvn C JQ--PhO^A#�,Q9 <br /> a ddrer>s LO1 vc! Jrl S�iI*IC3TOr1 City STocK ZtP 3 ZOO <br /> PROPERTY Owner P A F L, 6�55SC Pnone <br /> T1 r! CityB�K,L1Cl,�..zip ^ <br /> �_/ Addl'ass,3� . Phone# d <br /> c37 Contractor Ci1r o QA Li�k � <br /> Sao i +h Str � t� <br /> consulmnt f Sub Gontraator(IRS Address Range Section <br /> �, .TCNnsnip <br /> GIS Ceordinatss:X— <br /> D DESTRUCTION(choose type belaW) <br /> woRKT0l pn FORMED: QOVERBORE <br /> PT,G;OPt20EE,HYDROPUNCH,HAND-AUGER,OTHER") <br /> NEW WELLI BDRING(C 13 pRESSURE GROUT <br /> �VVELLxf w' GroutSReclfiwtlons: <br /> 'Other: <br /> COMMENTS. <br /> CONSTRUCTION SPEGIFICAT10N8 <br /> TyyE O�L INSTALtATION 7Y EOtt OF$aREHOI E _MULTSPLE CA51NG5?p Y=S ANO WELL CASING DIA:� <br /> IpMONITORING WHOLLOW STE=M <br /> prCTION Q AIR RAMMER ORIV=N CASING THICKNESS--�E OF CASING: ��EEL �P`1C Q O �iER <br /> p DEPTH OF GROUT SEAL,, TR6MIE TYPE TO BE USED: d AUGERS �'HOS>_ <br /> 13 VAPOR p MJG ROTARY ti (NOTE, MAXIMUM FREE-IrALL DEPTH IS 30') <br /> ❑AIR SPARGE 0 PUSH POINT GROUT SSAL PUMPED: I$ ns Q . a <br /> (j SOIL SORING a HAND AU GER GROUT SPECIFICATIONS: <br /> OTFIER APPRok BORING CEP�H PP C 10 LIE, <br /> BOLTED TRAFPIC BOX or (�S'TOV>:PIPE <br /> R10THER:� �Q CONDUCTOR CASING PROPOSSO?tel(Q,^(IT YES,list Sprofiratio^S hem): <br /> t;�tbl <br /> Clwlu�K,a: f� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS A CENCROACHMENT AAEIRED IINSp C ONS_ <br /> CALL THE UNIT IV INSPECTOR 48 WORKING <br /> I hereby certify that I have prepared this application and that the work will be crone in accordance with San Joaquin <br /> County Ordinances, Ru es a d Regulations, and all applicable California State Laws. <br /> TitlelCompany <br /> Sir}ned x _ <br /> � � Date S ��G <br /> PrintName tFARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FII-E,ADDRESS'. <br /> WORK PLAN DATED:_ <br /> � Doti!Issued. 1_ <br /> APplica iOn Accepted ey. <br /> Dale Final Irtsp9Ctian By <br /> Grout Inspection By <br /> besWClion Inspection By Date <br /> COMMENTS/=NDTTIONS:_ l cis 6' <br /> ACCOUNTING ONLY: AID# cava <br /> PE CODES FEE 1N1=0 AMOUNT REMITTED CHECK# REC'D BY DATL PERMrr I SERVICE RI=QUESTS INVOICE <br /> �`; �a-�� 8 �� s Dt� s <br /> C-57 WC_-WA:LVEi2 C-57 Letter of Autnorizaticn to Sign permit,_.,„Eneroachmen't doc,­ <br /> t�25� <br />