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06/10!2803 13 45 2894683433 FIFTH FLOOR _ PAGE 02 <br /> 1 - —L —�) yf <br /> � �L,PERMIT APPLICATION FORM SITE <br /> ,SAN JOAQUIN COUNTY III MGATION <br /> • _ , V50411 SMAVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> � -Weber, Third Floor, Stockton, CA., 96202 <br /> .2 Q� � (209) 468-3449 <br /> NON�xE�11NDAf3LE PeRMIt Inrpt�tt;S 7 YEAR mom-DAL—W'SUED n is m9de i1 cflr WWOO With San <br /> Application Is hereby adrnet e to San Joaquin County for a peto Thkz 2Pp <br />' Joaquin County Development Trtla,reamer 9-ii isz and the Standards cif San Joaquin County Env7onmercal Health DeparhnRM. <br /> Assezwm <br /> WELL Lunation 0 i OL5-r Z�h�T grass stmt Q r R L, cdy I�c L.1 ?.�3 36q-22 <br /> Owner Y SSC' - -�+dd Bpa�$D S• �m3_�cac <br /> C-57Conirar�or dress�r AdO Po ciy aE f Zip '(SPhon A '-313 � <br /> orasultant ub C Sia •ra. Adernss o rCL' y Ptwrre �125 �7. 03 <br />' GIS eomdinato&X______,Y Tow mtxp Range <br /> K TO 89 PgWORMED <br /> NEW WELL1 BORING (CPT.GEOPROBE.HYDROPUNCH,HAND-AtJOEA OTHER') p DRSJA ETER(cfiovse tY�below) <br /> p 5011 BDRiNG# �dVER-BORV-RE DDIAM <br /> GROUT PRESSURE TIONS <br />' COMMENTS <br /> +� 'p <br /> TYPdFINST T10H CO U IAULi <br /> PLE CASINGS j]MJ1THEVEL WELC4SIAG DU4 <br /> MONTORING *HOLLOW STEuDIAOF SORE <br /> Ij ExrRACTION p AIR HAMMEWDRIVEN CASINO THICKNESS l I TYPE tlF CASil+fG p STEEL PVC Q OTHER <br /> II VAPOR p MUD ROTARY DEPTH OF GROUT 5EAL ' TREMIE TYPE TO SEE USED p AUGAU p HOSE <br /> AIR SPARGE!OZONE p PUSH POINT(GP or CPnGROUT SEAL.PUMPED 13 Yes p No (MOTE: MAAMUM FREE-FALLIM, DEPTH IS 30°) <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> POTHER OTHER_ AppRoX BC>RNG DEPT Z'5 CONDUCTOR CASING PROPOSED �B (if YF-S'ED�FIspe�toons lOr ncorrimnt sedjan) <br />� �os <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby cerbly that 1 have preparati this application and that the work will be done in aCcomence with San Joaquin <br /> County Ord ln d Re ons,and all applicable CalFfomia State Laws <br /> Y,tleK3ornpany "O/M! #4M <br /> 4 Fes' <br /> Signed x <br /> Pant Nam Date <br /> DEPARTMENT USE ONLY - <br /> SITE MAP IN UNIT 1V FILE,ADDRESS: 'c• <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Cate Issued <br /> Grout Inspection By Data__ —ural Ir>�e�rjor,By Dabs <br /> Destruction tnspectan By Date <br />' t:QWENTS I CONDITIONS <br /> ACCOUNTING ONLY AIM FACO <br /> PE CODES FEE WPO AMOUNT REMITTED CHECK# REc'fl SY DATE PePiArr I SERVICE PmQuF-w 0 WV010E <br />,81 <br /> C-57 WC -WAIVER C-57 Leiter of Authorizesion to sign per (=xLCI'oachmerlt dot 9/34!02 <br />