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' 06/10/2003 13 45 2094683433 FIFTH FLOOR _ PAGE 02 <br /> f_J Y( <br /> U <br /> LL PERMIT APPLICATION FORM ;SITE <br /> USAN JOAQUIN 4COUNTY <br /> MITIGATION <br /> • _ pI` iYIRONIVIENTAL HEALTHDI=PARTMENT (EHD) UNIT IV <br /> ' .Weber,Third Floor, Stockton, CA., 95202 <br /> �+� •.`� PA (209) 4683449 <br /> NCMALEFUN LE PERM EXPIRES 1 YFJ►R FROM-PATE MSUED n Is made in nomAnn°+wM San <br /> Appkmft n Is hereby made to San Joaquin County for a polmd tO and/or Install the w«k dammed ThFs apprr�atro <br /> Joaquin County tsev*Wffv nt TiUe,Chapter 9-1115 3 and the Standards Of San.lomgWn County EeYf mncF"Health Dep P�-ssors <br /> WELL then LasT 2 1 i ,street Cay 1 r&Gx^ ��,Ip ., ��—317rt 22 <br />' pD� r RTY fJ dress s 3 i[� �i�rrR7A mp5_4M Phcne# L'5 23 i6 <br /> c-srco�tra (baa �r,ll.no�,aa Ott ��s���ay ZiDlq Phon19 4'zy-213-500o <br /> u�nrrt b r. sk►a� -- Ia, Adere� 4OD� c f:)+�r� r,,�,(�' ��I �rto+ tr 25 �2.►03 <br />' MS C menates.X Y Tow-"P R�9e <br />' K TO BEP OR%mv <br /> EW WELL1 BORING (CPT.GEOPROSE.HYDROPUNCH.HAND-AUG1rR,OTHER') OVER-BORE DIAMETER�tYPe�`") <br /> U SOIL BORI,I,N,,,,G���0��} (a PRESSURE GROUT <br /> o --�1 2 GROUT SPECIFICATIONS <br />' COMMENT'S <br /> TYPE OP ISL_ OiSTALLATIONrE C_ ONSTftU O SP moms <br />' jkMONrTOmNG *HOLLOW STEM DIA.OF BOREHOL 'k��MULTIPLE CASINGS fl MULThLEVEC WELL CASING DW <br /> lI FXTRACTION (I AIR HAMMERIDRNEN CASING THICKNESS � _ —TYPE OF CASING 0 STEEL JKPVC H OTHF.FL <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREM IE TYPE TO BE USED (1 AUGERS ]]HaSE <br /> 140 AIR SPAR6C1OZONE u PUSH PUNT(GP arCPT)GROUT SEAL PUMPED G Yes Q No (NOTE: MAmmUM FREIE-FALL DEPTH IS 30') <br /> Ij SOIL BORING Il HAND AUGER GROUT SPECIFICATIONS <br /> Ij SOIL R HAND <br /> 9t3RltyG DEPT Z'5 BOLTED TRAFFIC BOX or Q STOVE PIPE <br />' CONDUCTOR CASING PR0POSZD (If YES,r'st spe�tz 'n cmriment gacLon) <br /> commm T5IT <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREI=MI=NT OR ENCROACHMENT PERM <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> l hereby C*rW that I have prepared this application and that the work will be done In accordance with San.Joaquin <br /> County Orden d Re ares,and all applicable California State Laws <br />' rtlelcorr,pany <br /> Signed x / <br /> Pnnt Name- r���t /0—v�t,InOt� ° s <br /> • - DEPARTMENT USE ONIA - <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �• <br /> IV <br /> WORK PLAN DATED:" <br />' Appilcotion A=cmpted sy Date Issued bad " <br /> Graut Inspscbon Sy C1ata_ FiirW Um pecrion By <br /> Destruction ImPcaO By Datta <br /> CQIKN ENTS I CONDMONS- <br /> ACCOUNTING ONLY A1F5 FAC# <br />' <br /> RECD BY DATE Parr/SERVICF=�UIEW 0 <br /> FEEwvotcE <br /> P9 CODES INFO AMWNT REMITTED CHECK 0 <br /> sR# �3 <br /> C-57 WC -WAIVI=R G57 Letter of AuthorizatiGn tO sign per'�t l=ncrnachmetlt do 9/30!02 <br />