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JUN -24-03 11:04 AM BE' TNC. 909 9�9 9556 P.02
<br />06/24/2003 05:41 2094663,__ FIFTH FLQCR PAGE 92
<br />WELL PERMIT APPLICATION FORM SITE
<br />SAN JOAQUIN COUNTY MITIGAtION
<br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV
<br />304 E. Weber, Thiry! Floor, Stockton, CA., 96202 � —
<br />(200) 4683449
<br />NQd,2FFU.QA,Rj.E P§a gh.AT�.18. A42
<br />Appilueiion is hereby mmde tri SOA Joaquin CCU*fo' o p6mlit to wristruet andltu'nstail t work db9Grl0ed This 2pD11ri# 1pn M made In pompUance Nam !San
<br />Joeq,1.� County DeYeiapMent Title, Ghapt9' Ii -91' S.3 and the Stand'drda ofSam, j"Quin County Criy1mn-nental Heallt, ¢rpartmert.
<br />��,f AnQ2caars
<br />WELL Lci atlon J42S 14r _ _CtoaE 5trt et T . _. �1 I-'
<br />lgtAP'E1iTY0wner� _.Addreea39%I�,fhYlk I & C�._ SID 10 PhOM rr �
<br />C-97 Contractor, , r# _ _ ^-Aodreai +' ivmm W1_.G TrRS �,p Lic#, TUBI Phnhett 0 7 Z'
<br />Consu"aW I W) CCF!tracto j.�' Pddr p9 , rY1� „- _CkY,GL =,LIc' _PhanBitr� s x-
<br />Rainge-- -. — -
<br />SRkQ
<br />FEW WELL t �M3QRlNd (:+ie7, QEOPR4BE, HYDROPUNGM, HAN(>-AUGEIi. O'i'MER') p DESTRUCTION (ettaoso below)
<br />a soil. 50RIN n OVER- RE
<br />wEl.l ip �11L: araeuRcRauTl
<br />'t)tlrar...,----_.__...�.�..�� GroutSp9ciflcae;p„G: �� •}is:,,R_ 114
<br />COMMENTS:
<br />ME 01•_btLLL TY� CG1NltTRUC'IIhN�PFL Q� ��
<br />ymoNITOR-NO OLLOw $TEM DIA, OF I3CREHOLE i h+ULTIPLE CASINOS? a YES )1:�n wPt,� CA51Nt� OIA � �„
<br />(j EXfRX7TION AIR HAMMEtiGRIVEN CARING THiCI^'NESS TYFE 01' CA91N0; p STEELxPvc a o1'F,Ek.
<br />D VAPOR jj MUO ROTARY 0cP7H OF GROUT SE 7REMIE TYPO TO BE USED. )(AUGERS p MOSE
<br />p AIR SPAR P,IF a PUSH POINT GROUT SEA.- POOPED: a Yes JrN6 (NOTE., MAXIMU FRE - ALL DEPTH I5X0j)
<br />nSOILDOPAG DHAND ALICJPR Gk0UF$F5C;1HC;ATIONS'_,,� 1�.I
<br />a OTHER T_ ._ ._A 4THkR APPROX, BORING AEPTH �_ aOLTEp TRAFFIC BOX Of D edVE PIPB
<br />00NDUCT011 CAOIN© PROPOSED?_ __ (11YEt1 lint speclticallone hare1,...w..�.r —
<br />'COMMENTS:_--�—
<br />_ NOTE: OFFSITE BORINGS REQUIRE ,ACCESS OR ENCROACHMENT PERMITS.
<br />CALL THE UNIT IV INSPECTOR 46 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS
<br />I haraby certify that I have preparod thle appliCatlon and that the work will be done In aQcerdanae with Ban Joaquin
<br />County 0rdinanc ,Rules and Qulatlons, and all appllCalhle Cal IfornIa StAta�1�
<br />aws,
<br />V9nidK ,.--� r . TItIdCAmfnGl.�
<br />PCntNdms �-
<br />SITE MAP IN UNIT IV FILE, ADDRESS: 4 257 L4Y,C4?
<br />WORK PLAN DATED:
<br />11
<br />AmlloiEoo Actxplad By f li ....x Lam: � , zr pate irsued J n
<br />Rraul Irapmbon By., if 1, r --.. ,Data G. L� ��,, Final ',nep6 Wm !!Y ` ath G L� 3
<br />COMMENTS/CONDITIONS: -Z
<br />ACCOUNTINGONLY: I AID*
<br />a• rtir
<br />PE COri 16 PCC INFO AMOUNT RCIWRED CHECK* RFr'p BY OATL
<br />Jnr
<br />C.57—_ W6_-WAIVERT C-57 Lo+tcr of Authorization fe S gn pertniT�
<br /># I INVOICE
<br />!/25/02
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