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AUG 6 101 11:53 FROM GETTLER RYAN TO 12094683433 PAGE.002i003 <br />02/23/2001 10:05 2094683433 FIFTH FLOOR GRAGINAL <br />WELL PERMIT APPLICATION FORM SITE <br />T CATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />ENVIRONMI=NTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA-. 95202P <br />(209) X468-3449 MN <br />MIT XPIR E R T8 55u <br />o .REF MDA E caijon b made to CompL_Av) <br />�ppliCauon is hereby made to San Joaquin County fora Permit I* ConswR andlor install thf work desenbed- Thrs gPPI' Assess jh <br />laaquin County rcby Mpmgr:t Tide, Joaquin <br />r X1115.9 and the Standards of San Joaquin County Public Haalth Spt"iiCES, Envirohmen�l �' '2�i l �ZU/ <br />I City S ► n Zip G1_ 57 � Parcell/ <br />dYELL Locetlon "� Cross Street -mos �_ <br />- I r , -I,,- RC2.e t Phonekt- S1 Z3 - 3 d cv <br />PROPERTY Owner �•+ Adarese �.�� �. _ _ T <br />,•`- 1 City,RLtj if .r'PaF4S Lidl �� Phoneft, � y t _ � �4 y <br />� L Atldrr<ss ` �� 5 - 2 <br />C-67 Contn;dor 1 t �� } <br />i7 �.ZoS Pnono+ha«� <br />Consultant / Sub Gonfractor hL. A4draaa <br />Range SCWon <br />GIS Coordinates: X . Y .Township ' <br />WO RK TO P>ERf>?BMSEO= (I DFSTRUCIlm (rtwoae two below) <br />p E <br />OR�UNCW. �O'AUGER, OTHER) OVER•BCR <br />BORING CPT. O GROUT <br />l <br />a NEW WELL) <br />� <br />13 SOIL BOSE. pRESMP- <br />WELL e AALAI - IGrout SptcfKatfor+s: <br />'Other: <br />COMMENTS: <br />t\ <br />�rw4TRUCTILIN $PEGI1rIGATIQ I <br />TYPE OFA INTt t` MULTIPLE CA$1NGS? 0 Y£S tI NO WELL CA3tN0 DIA: 2 <br />OF 80R£MOLE�.—, <br />13 STEEL I PVC 0 OTHfiR <br />MONITORING it HOLLOW 51 EM plA <br />I TYPE T4 BE USED p AUQ�RS f1 � tdS <br />Q AIR HAMMER/DRNEN CASING T1i1CKNESS —TY OF <br />L <br />O <br />EXTRACTION <br />Q vAPOR a MUD ROTARY DEPTH or GROUT SEAL MUM FREE -FALL DEPTH IS 301 <br />Yes ONO (NOTE: MAw <br />6 RIR SPARGE a PUSH POINT GROUT SEAL PUMPED: R <br />GROUT SPECIFICATIONS <br />HAND AUGER 0 5OLYED TRAFFIC Bax or G STOVE PIPE <br />h <br />-n <br />B =L BORING pi <br />pPPROX. BORING DEPTH _ _ <br />p OTHER: tl OTHER`S S. Gst speaflrations hers):�,�. <br />CASING PROPOSED?�� if YE <br />CONDUCTOR <br />'COMMENTS: <br />OR ENCROACHMENT <br />NOTE' OFFSITE BORINGS REQUIRE ACCESS 5 - <br />AL D NSPECTIONS• <br />CALL THE UNIT IV INSPECTOR 40 WORKING HOURS IN ADVANCE F)R <br />lication and that the work will be done in accordance whit San Joaquin <br />(� <br />i hereby certify that I have prepared this a <br />County Ordin3nSA R►�ites�Dd ft ti s, and 811 applicable California State Laws. <br />Signed <br />Pnnt N <br />UA <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />p <br />WORK PLAN DATED: <br />ADpucation A oW d <br />C,rowl ku"&on By - <br />COMMENTS $ <br />y_ <br />COMMENTS$ <br />ACCOUNTING ONLY: I AIDII <br />An= o� <br />Date lssved Oke_ . 2,`p- OZ <br />Final In"Ction By <br />PERMIT / R <br />REO tdST it vulUt <br />PE CODES FEE INFO AMVLrN7REMtrtED CHECK>s R DBY PAT �1'- <br />+ r----�_e�20 <br />9/27/40 <br />C-57 Letter of Authorizotion ro sign <br />C-57 _ WC__ -WAIVER, <br />F5$ 23 '01 10:00 2-094683433 PAGE -002 <br />