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08/21/02 FRI 12 11 NAX 1 916 861 0430 Sh(,UK--SALKAMh1N1U sr,uux atto rnr►iv Wj UUO <br /> 06/21/2082 86 20 2054663433 FIFTH FLOOR I PAGE 05 <br /> ` 0AU -g <br /> ---------------- <br /> WELL PERMIT APPLICATION FO ! M SITE <br /> MITIGATION <br /> SAN I MITIGJDAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT 11f <br /> lVIRONMENTAL HEALTH DIVISION (PH5�I=H0) <br /> 02 JUN 19 PIi 1' 4 E. Weber, Third Floor, Stockton, CA., 99202 <br /> (209) 488-3+449 <br /> Ng"gMHDABLE PERmrr caiggs I VEM FROM DA u <br />,ppfcman Is hereby made to San Joaquin CoUnV for a permit=construct andror Install the work descf0'4 This spplreauon Is made In c ompllanCa wllh San <br /> oaquin County DirmPppmenl Trtle,Q1Spter W1118.3 and the Standards of San Joaquin County Public HeaEth 9*m4ces.Envrronmenfal Health blAr-jon, <br /> xE.L Location 14.1 / � �",[ —Cress Snmai •*r+'{City,; ��'��P� Parrxi# ~� <br />&ROPERTY Owner,.. Qty_ Ziphone <br />.sr cnntractar. areas < r�rP 7rZF mphons AV6-4rB <br /> jgnsultasl 1 Sub Contra�r r� —ASE <br /> /� eS �Crty. �e�l � <br /> a"I5 Coordnates:X Tawnsh,p Rsnga_� SBction <br /> N RKT13 BE PERFORME DESTRUOTION(ahooso type below) <br /> WELL/BORING(OPT,GEOPROBE HYDROPUNCH.HAND-AUG8R.DTHFFrj Q 11 OVER--ORE <br /> 1]SAIL BORING tt PRESSURE:ORCUT <br /> nwFi-L <br />'Dthe� Grout Speciticatrons <br />:;UMMENTS <br /> E OF WE L N ON TYPE Gd U SPE CATiOTiB <br />�MONI'I'DPIING QLLGW STEM DIA.OF BORE:IiOLE, r <br /> !i MULTIPLE CASINt9S1 j]YES D WELL cAswa D� <br /> WAPAB <br /> CTION AIR HAMMER/DRIVEN CASING THICKNESS,��Tr'PE OF CASING: p STGEL 'PVC []OTHEA--—� <br /> Q 1]MUD ROTARY OE=P'TH OF GROUT 5EA Y � TREMIE TYPE TO BE USED: �iJpERS ❑HOSE <br /> OE APUSH POINT ol3ourS9AL REED �'es 0 Ho { �� �AKIMU FREL�FA1..fr DEPTH 15 3a') <br /> owt <br /> p SOIL BORING []HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER. n OTHER �a.PPFEOX.90SING DEPT if 130LTED TRAFFIC BOX ar p STOVE PIPI= <br /> CONDU=OFt CASING PROpO8ED7 (H YGS-1101 specrtieatra18 h+ra) <br /> foommoffS', <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances RU110a and Regulations,and all applicable California State LsWs, <br /> Ti1le/Comparr]I—�iri s/J _!�-fT�it ,� <br /> 3lgned <br /> I3EPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE,ADDRESS= <br /> WORK PLAN DATED" Z C. <br /> nate lesuadA 2-n Q An <br /> &ppilmdon Accepted$y �_pata nal Inspection By�G Dasa r� <br /> smut Inepachon 13 <br /> oesuucdon trropBeean By date <br /> COMMEN I I CONIUETEDNS' <br /> UN71N6 OINL_Y_ A1D# ear`+ <br /> PE CODES FM WFO AMOUNT REMFF TFA CHECK 6 R1EC'D BY DATE PERMIT I SERVICE REQUEST lR INVOICE <br /> 3 5-0 l �`l_o rJ SZ6�o3�f l o`z Rot 3 0 <br /> C_57 WC -WAIVER, C-57 Leiter of Authorizctlon to sign permit Encroachment doc 9/Z7/UU <br /> 3 <br />