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06/21/02 FRI 12 10 FAX 1 916 861 04JO Sh(,0X-SAUKAMhA1V Lvj UVO <br /> 66/21/2092 BB 26 2094683433 FIFTH FLOOR PAGE 03 <br /> WELL PERMIT APPLICATION FO M SITE <br /> � MITIGATIONSAN JQAQUIN COUNTY PUBLIC HEALTH SEA ICES VITT A <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CIL•, 95202 <br /> (209) 458-3449 <br /> pEjERMIT ExP1pR8YEAR ATE BLIED <br /> kppleealan is hereby made to San Joaquin County for a permit to corralmet and/or Inatali 11wwank desarllsed Th1s appllr�tlo�is made In mrrtpAan�writh San <br /> iotaquln County Development Tlas.Chapter 9-111 s 3 and the Standalrds of Ser+Jaaquln County Public H•alth SeryQAeY1 �ees,Errvironmerfts�1�Qlhrlslpn <br /> Cnrss street Gty_ y,P �aroel# <br /> NELL LOc�t1Q - �=,T ar? <br /> 3ROPEt4TY Oumer <br /> rocs 4 dJ!� CITY r p ����Phonefi <br />►57 Cantrardor Gtr Address ?��a �fi G e�i�-City�P�L#�phonei 6 <br />�en�ult�rlt�s�Corrtrar�,��,� _Address <br /> GIS Caordh8te8 <br /> Y_ Townehlp Range-.I Section <br /> C T-0ME EREORM []DE57'RUCTIOrV(Chou"type bola-) <br /> '*EW WELL/BORING i OPT,GEOPRCOF,HVDROPUNCH KANO,-AUGER,DTHER1 p GVEK-80RE <br /> Q SOIL BORING -��- U PRESsUF4E GROUT <br /> iH1=1.L# Grout Speoilicatiorts <br />•ether_ <br /> COMMEWS <br /> JVPE OF L INSTALILAT1024'tW CONST Ugma"spgcmTIONS f! <br /> *ICWITORINC LLOW STEM IDIA_OF SDRFhHO E_ VW MULTIPLE CASINGS?p�f1=S .r4o WELL CASING 00 f <br /> 0 GTION AIR HAMMERlDF11VEN CASING THICIWESS �!T'lEE OPCASING []BTEELPYC fl OTNEI� <br /> R U MVD ROTARY DEPTH OF GROUT SEAL. TREMIE TYPE Ta BE USED AUGERS U HOSE <br /> U GROUT SEAL PUMPED- Yee a No NOTE:MA)CIMUM FREE-FALL DEPTH IS 30) <br /> Q AIF SPARGE PUSH POINT S f�lrl— r�v!>9!�- <br /> Sal.BORING U HAND AUGER AppR 1r SPECIFICA7iDN5._ <br /> Q p`jFIEfI <br /> tTINE AFPROX BORII�[,1 p6PiN 1 r OLTi=D TFiARF1C BOX ar []STOVE PIPE <br /> CONDUCTOR cASWG pROP09ED� (If YES.its;apao��cns here) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IY INSPEGTCa+48 WORKING 110URS IN ADVANCE FOR ALL REtUIRED IN <br /> SPECTIOrgs- <br /> I hereby certify that I have Prepared this <br /> hi a application <br /> and <br /> tit the <br /> C�llfif work <br /> i Stara he don <br /> 10 iLawsaccordance with San Joaquin <br /> CoGnry Crdin�nees, ales an A �f <br /> TIUe/Compar5y �r�/�d <br /> nod r <br /> �� <br /> jr.41 <br /> mate <br /> Pent luama. p PARTI4ilENT U <br /> 5fi3ONLY <br /> SITE MAP IN UNIT IV FILE,AIDPAESS: <br /> WORK PLAN DATED: z S o <br /> Date issued Zo G? ma.. <br /> aPRScatron Ae;aepted sy <br /> pato Final Inspection By Rita <br /> Grout inspecdon 8y <br /> Destructionutepuman By <br /> Data <br /> CotyNff TS1CONDM014S' <br /> ;NG ONLI'. AID# rrr�iPEClii1FG AMOUKrREINED CI'O # RlECa 8Y DA7x PHRWr I SERVICE REQUEST# PAVOICE <br /> Z c)3 S9l271DO <br /> r,,57 — IN[ WAIVER, C-57 setter of authorization to sign permit EncroacFtlnerlt doc <br />