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-FROM Geo—Phase Environment -1c. FAX NO. : 2095690295 May. 16 2003 01:39PM P2 <br /> 06!16/2803 11; 03 209�1653a3 FIFTH ;LOCR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL.HEALTH DEPARTMENT (SHO) <br /> 304E.Weber,Third Floor, Stockton, CA., 95202 <br /> (209)469-3449 <br /> ON•R FUNCA P P FROM DaEJIMM <br /> Appita$a Oft Is hembY matte to San JOBQ6Uln County 9r a permit tC tonBWC andlor Intt2ll the work descriDed. INN ap kavon is made in cwmprtance 4v `San <br /> .Joaquin CvuAy 0evejMrnentTRle,Chaptar 901{8.8 and ttte StandVde of&art Jo quin t cUnp/ E11�irontrental Yt'31U1 DQyFltimenl.AgSe�ot <br /> WELL Lxativn S. Q �'s Croaa 5traet�a��iE! Pt�els Z " <br /> r � ®" y <br /> PRGFE9TY 0wmw� <br /> AdGrOSs/O� S/iNv �Ciy Sd GTxa gtp�,�Phonef��fG. �.? ��.��' <br /> C.sycontraGnrL�r' / address '� Y SSGYeztp9y/LivN714.��ii�hon �7'7 �� <br /> Corauttant i Suo CiQntra <br /> M A.ddrasc G�tyL!c� phone4F�4} 3C�d.2�f.3 <br /> Gl$Coordinates:X� Y.�—� <br /> Tbwnstilp Ranga SeCtcn <br /> ORK70 St PE FOIi DEBTRU�TiON(chaoss typo t�plvw`) <br /> G NEW WELL/RGRiNO(C, EOPRORIN3#DRO~UDiCY>NAND•AU q.OTHER') a OVER-SORE <br /> 1,WELL <br /> Q PRESSURE GROUT <br /> 10tht� Grout 5pacibGlt:One! <br /> COMMENTS; <br /> )YPE9RY1F4L INg7gLLAYItxJTYPE CONSTRUGTONBP CIS iIG�Y�Qh$ <br /> Q MONI fCRIN3 HOLLOW BTEM CIA.OF BORPHOIE��MUL IDLE CASINGS?U YES Q'vO Y+ LLGA81lYd l7iA:�d� <br /> p EXTRAc rICH p AIR HAM�18RlaR vEN CASINGTHII.I iESG ____/__-YPE of ewat,ING: p STEFL 0 PVC pOTHEF2' <br /> D VAPOR Q MUD ROTARY DEFTH OF GRCU7$ <br /> ,..�7FtENlE TY?e 70 BE USED: J3 AUGERS d"DSE <br /> 1J AIR SPARGE POINT OROVT SBA:PI-IMPFC: J�YQG a N9 (NOTE: MAXIMUM FREE-FALL,DEPTH 15 30' <br /> SOIL BORING 0 BAND AUGER GROUT SPECIFICATIONS' <br /> 0 OTHER; .�OT'HE� �--, °BP'�OX.13QF21N3 QEPT ice-.' D a BOLTEC TRAFPIG HOX or D S70UE PIPE <br /> CONDUGTOR C ii IG PROPOSED? ,(if T[8.!i9t spaclficxGo�s hare)_ <br /> rr � <br /> •CPNILtENTS. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OLS ENCROACHMENT PERMITS. <br /> CALL THE UNIT;V INSPECTQR 48 WORKiNG HOURS IN ADVANCE FOR ALL REQUIRED(NBPECTIONS. <br /> I htarehy eOMY that l have prepared this application and that the work will ba done In accordance with San Joaquin <br /> County OrdinanctS,Rule and Regulatlo and all appil"ble California State LaWI:. <br /> TtyerCcm151lrty Po ��dlrt9 <br /> Signed <br /> r— d l2 r 61 Dais <br /> Frrt>`or•o pEp MENT USE ONLY <br /> SITE MAP IN UNIT N FILE, ADDRESS' <br /> WORK PLAN DATI`D:� l <br /> bd" �L�6-� Q Area � � U <br /> 17ate;ssua <br /> AppEloatien 0.xepced 8y <br /> Grout Impa:98m By Ci a inAl kwppd or,ay <br /> tlesEvctlen Inop¢ctian gY Dais <br /> CQMMEWM 1 CON0trlCN3 <br /> TjjF:9EjNF0 <br /> AIDO0peCOpIm AMOUNTR1ri n_MD CHECfl;� RECD SY DATE PgRMrr I SERVICE REQU ST tYINYOIC6 <br /> o� " 4'` 377 o s 033 3 <br /> C-57 Le Ttr of Authari=tion to Sign permit_EnCr0cChment docL— 1/25 <br />