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09/20/2002 15 07 2094683433 FIFTH FLOOR PAGE e2 <br /> WELL-Y: ER IT APPUCATION FLYRM �SI?E <br /> ' SAN JOA u MITIGATION <br /> a tN caur�TY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHC)) uNrr IV <br /> ' 304 E- Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> EQN4 U?J0A2L-e PERMITE)pM S 1 YEAR DATAt55UED <br /> do2quoon C is herby iap a nt Sart Joaquin hapte County fcx a pertri+t to Corrstn id dlor�nstall the work descrrbed �hrs appifradorti rs made m a mplianCe with Sart � <br /> loaqu�n County C1e fGpmer�t yT`fie,Chapter 8 1115 3 2rj(! farttl2rds of as h Cr,�„►pl En�nranmental Health Deparftwit <br /> wrvL,L L.ucatlart,� �} q�G,tY '31 <br /> Ptzo� rYOwner rL l /Z Ado,, o Aril 19-tr� cuy Ill -NLK#zip!L1 pt0l ? <br /> j 'on3 <br /> CS7 CanErat3ar� �I +'1 A�aress �Lw rrl C Ci cay_�� ,Fp s �„ 7�7�fflphon DSL? <br /> ' Consultant r sub cor,lra�r �. � �.- Address 83 S <br /> •C�yS eC�Ta c�._._�phon g t y fo a b <br /> GIS Coordinates_X Y TownshrR Raroje Seam <br /> 'tAft]RK TO FIE Pte. - <br /> KNEW WELL,/BORING(CPT Gl~QPR.0eE,HYDROPUNCH.HAND-AUGER,CTTHE,-� a DESTIiUC F70N(choose type 6elaw) <br /> Il SOILBQWNG� <br /> []OVER-BORE <br /> '*Other �W ELL# V11- 4V ~ Gmut$pecrlcaftr= 13 PRESSURE GROUT <br /> COMMENTS <br /> TYPE OF WIEt_L INSTAJ-I-A' N 7YQE GC7NSTRllt;e70}I SPE(,IFtCATI[3 <br /> a MONrEXTRT'ORINIG ` }EDLLOVY SiEild DIA OF BORE}1OLE�_ MULT[F+L E CA$INGS�d ye$)*O WELL CASING Dtk � _ <br /> U FAPOR 7-!C)NI a AIR I.17�MMEVORWIEN CASING THICKNESS C% �—TYPE O CASING [�STEirL C THER�exw/ <br /> LI VAPOF2 13 MUD ROTARY QEaTH OF'GROUT SEAL ZS' F+'—TREMIE TYPE TO BE U� 4�aGFFtS HC)SE <br /> PARGly p I�t1SH POINT GROUT Slrnr PUMPED p Yes Aro (NOTE MAXIMUM FREE-FALL DEPTH IS Sol <br /> BORING Q HAND AUGER GROUT SPECIFicAnot iS T <br /> 7 OTHER-_ ti OTHER APPROX BORlNIG DEPTH f?10� P@pLTED TRAFFIC 6CYX ar (]STOVEPIPE <br /> ,G 5 c4`wt+-.t CONDUCTOR CASING PRtOPOSED,) !A/t7 ifyM,Elst <br /> ICOMMENTS.- 5-G.- P �v q D spesx5rr+tlons ltere� <br /> 2 'L <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL.THE UNIT IV INSPECTOR 48 WORKING HOURS IN ACIVANCE;FOR ALL REQUIRED INSPECTIONS <br /> hereby Certify that I have prepared this application and th4t the work Will be done in accordance with San Joaquin <br /> runty Ordinances, Rules and Regulations,aced all applicable Callforri to Laws. <br /> rgned x 7`rtlPlcomp2any ` C L'T� p�F ! 'j 'U <br /> �rrt Naj�ft <br /> Date 0,9—11 -O Z <br /> DEPARTMENT USE ONLY <br /> �RTE MAP fN UNIT IV FILE,ADDRESS: <br /> IORK FLAN OATm- <br /> phraWn Acres By. 1. W __gZ�Q G-+�O <br /> Issued Are <br /> lnspeCban Hy D Fatal Inspetlton By —Date <br /> Bstruciton Ingpechn„gy Date <br /> mPMMENTS carnmotrs_ <br /> r <br /> 5UffK-nNG ONLV Ala# <br /> FLE INFO AMOUNT REM"7ED CHECK# R2 C aA1TE PERMIT/SERYIGE REQUESTS INva <br /> gf.© 7 lfi/ �a�oL sR# 17 <br /> 0 <br /> -57 WCC WAIVER C-57 Letter of Auth I o Sign perrnrf�-_Encroachment doe 1125/02 <br />