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2094693433 <br /> 041:02/2009 10:21 <br /> EHD PAGE, 03;.. <br /> -San Joaquin County - __ _... -- <br /> ' Environinental Health Departm( <br /> } $ITt= <br /> �� ITIG;o►` ION, <br /> 304>~ast Weber Avenue,3rd Floor,Stu,.ktan,CA _ <br /> (209)46$3444 Fax:(209)468-3433 Web:wNvw.s}gov:ozgl 10� MT:�V` <br /> F! = .. .. rfllfell:Perm�t_APp,rI�FRo�nDAT .IERV#.ROk�+4EN7HEA�TH- -- - . <br /> NOkLREFUNDAeLE PERMIT.ExPIRES S MkT1S�R1lICi � _. <br /> Applicahan is hereby fttade to San Jagtiin County:for a permitSto consIrva <br /> ds of saelo aquae County ll the deSr im eta HI ea{th Drepan n a I in e°mpl[anre+�th San <br /> Joaquin County Develapm@rit Tale,Chapter 11-1115.3 and the Assessum <br /> . Rnse Marie. Stockton Zip - <br /> 95207 Pareet# <br /> p i . <br /> 45ao if Avenue/Frn <br /> ot � <br /> ao66Street �—City�� <br /> WELL Location - <br /> P�tOPi cit . . <br /> Stockton ZIp95a02 phone#43719561 <br /> Cit of gtoCkton Address 345 Norah El_Doxado StCitY <br /> Owner Y Diamond Springs 484369 530 544. 16a9 <br /> ,...._` Al1�t�eTT'Aban�idnmPrit• ,... . 662fi...fr�ezahandise Way City_ Zgp9S619 Lidk . Phane#�� __.-_....__ „_....,_..-. <br /> C-57 Contractor ddress------------ <br /> • Phone# isnaYa57-1ti46_ <br /> iAddre56 s37 Shaw Rd Glty scockton Lic# aan�a7 <br /> Consultant)SLIb Cntr v $2ction <br /> Y T4wnshi¢, Range <br /> GIS Coordinates:X <br /> RK Bt P FOR D: <br /> p,NE"V1f:WELL BORING (CPT,GEOPROBE,1 IfPROPUNCH,HANG-AUCaER,Q7HEit") �OVETR gop.E 1 DIAM(�ER 8itype <br /> , fi nch <br /> g SOIL BORING# wt.t wvcti,bf aweirl,�yrl'+Pz $PRESS SPECIFRC ICATIONS <br /> OUT <br /> ©YvELL# GROU7 sPEG1FICA7ION& or ad <br /> COMMENTS_ <br /> po INSTA 01�fYP� <br /> CONS CS1D SPECIFICA ONS 2-171, <br /> N]ONffORJNG t HOLLOW STEM <br /> D1A.OFt3r7Rt=HpLE$'IAw �IJIULTIPLECA5INGS pMULTl-LEVEL JVVELLCAS1NG41fu�.•—.. <br /> T`(PE OF CASING: ]]$TEEL 4 PVC �{OTHER'__�' <br /> DCYRACTION a AIR KAmMF_R/DRNEN CASING T1ilcwsESS�w TREMIE TYPE TO Bs USED: B AUGERS, 4 HOSE <br /> VAPOR MUD ROTARY DEPTH OF GROUT$EAL--�� <br /> a A15 SPARGEI OZONE U PU5H POINT(GP cr CP-I)GROUT SEAL PUMPED: a Yes U Na (NOTE: MAXi{NUM FRi=i -Fat-L BERTH IS-30-11` <br /> l]S01L BORING 4 NAND AUGER GROUT SPECIFICATIONS <br /> ROX.BORING DEPTH p BOLTED TRAFFIC t30X or 0 STOVEPIPE <br /> d OTHER; �.II OTHER• App (if YE9,l-st sped)-EanB In rOMMBnt 6eation) <br /> CONDUG7t]R CASING PAOPOSF-0 - <br /> COMMENTS: <br /> SQUIRE ACCESS AGREEMENT'Oft ENCROACHMENT.PRMfTS. <br /> NOTE. OFFSITE BO 4A <br /> R <br /> AA WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this appliration and thatthe work will be done in accordance With San Joaquin <br /> County Ordinances,Rules an Regulations,and all applicable California State elves. <br /> fiitlelCompany <br /> Signed Date <br /> Print Name I <br /> . DEPARTMENT USE ONLY � <br /> SITE MAP IN UNIT-IV FILE,ADDRESS: <br /> WORK PLAN DATED: ( ' <br /> a� I Area <br /> Dais issued, `��i�� I <br /> ApplicationAccepied By Final Inspeaiion By Date <br /> Grout Inspection By Date <br /> Destrucdon Inspection By Date <br /> l <br /> COMMENTS f coNDITIONS: <br /> ACCOUNTING ONLY; AIDS 5AC1t <br /> PE CODES FEEWFO AMOUNT'KEM1TTED CHECK# REG'I7 BY PA'ff;r p SR T 1 SERVICEyf�y2�EQU1:3T# INVOICE <br /> O �Or7 4✓ t7R4��yaL�7 ! � F� <br />