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QCT-30-2003 13 54 CAMBRIA 1707 935 6649 P 02/02 <br /> 1 ELL PERMIT APPLICATION FORM g <br /> • i' �� V SAN JQAOUIN COUNTY MMGATION <br /> JUN g zed ENVIRONMENTAL HEALTH DEPARTMENT (EHO) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> " . .NMLNT HEALTH (209) 468-3449 <br /> ;=,t,lwIT/SERVICES NON-IiEFUNaAB G P7r1� EJCPIRES I YE!►K1 FR014t GATE 15SU <br /> Application is hereby made to San Joagwn County for a pernatb construct andlor Install the work descAbad This applazdon"ss mado in compmnce wdh San <br /> Joaquin County Devalop"MA TI4a.Chapter 9-11153 and the stanurds o1 San Joaquin County Environmental He%Ah Departrnent <br /> WELL Location � V'S'Or � Crvss ZA6 p95��9f�7 <br /> PAOPEimowRor s LPs....:,,��5,., 2�-tq G.JQ' 4[�2�Clty ''� •� p�S l Phnr1 �l -z�1ra <br /> G57 Conerxlor r �-�9-50 No _ C / 53,L,�cf Yom'Phan zs 3��-511soa <br /> ConsulRnt/Sub entr l-_+cs r-' .xh- ' 7-Sq Gty `".-_L+olt�6 hpr►eA X35-`!'a.SD <br /> GM Coord nates.x � �`�_ -.Townsfnp Rarsga - Sema <br /> WMX TO_I!E PERFMMED; <br />&NEW WELL /BORING (cirr.asopRom HYDROPLINCH.NAND-AUSM OTHER.) -p OESTRUMION (dense type below) <br /> a SOIL BORING# 11 OVER-BORE. DIAMETER <br /> ;{w11FL1.M w_ 3 �,• Mw-rl 1)PRESSURE GROUT <br /> .� GROUT SPECIFICATIONS <br /> COMMENT ' <br /> REIN[- � ITISTAL1ATi011 T1(PE COIISTRUCT101J SRECIF) A l/ <br /> 2NONiTORING HOLLOW STIA,op soRI:HoLE S Q ML LTiPLE CASINGS Q MULTI LEVEL WELL CASING DIA <br /> $ EM D <br /> 13 EXTRACTION a AlI1 HAMMERNRIYEN CASING TtilCMESS S�G.Bo TYPE OFCA5ING: [�STS. ,KPVC 4 OTHER: <br /> R a MUD ROTARY DEPTH OF GAOUT SEA -Ss"S� TRWG TYPE TO BE US )KAUER <br /> GS a HOSE <br /> DIMPARGE/0ZOME p PUSH POINT(GP or Crn GROUT 4EAL PUMPM` Yes tl No (NOT9: MAXIMUM PAEE-PALL DEPTH 1S 301 <br /> a SOIL BORING Q HAND AUGER GROUT SPECIFICATioN3 pe ( A <br /> a OTHR OTHER , APPROX.BORITtG DEPTH t oo� <br /> EXBOLTED TtRAFF1C BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSEd Na. (if yES,Ilst speaf►cabcns to comment section) <br /> COMMENTS• <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances,Rales and Regulations, and all applicable California State Laws. <br /> Signed k �- Tcsrcmparry t� S-f 4'� c. r i <br /> PNnt Netrno GG : PauQ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT Iv FILE, ADDRESS: <br /> WORK PLAN DATEm <br /> ff <br /> ApPMlMdon Accapted BY ' pass Issued "V <br /> araul Inspecfim BySte Fir►a!Inspactlan el►,_ Date <br /> Do--truenerl lnspeclen By Dare <br /> COMMEN131 CONOMONS: <br /> KM <br /> NLY Alps FAC <br /> N INFO AAIMOUNT RELUMP CHECKs C'D By DATE PERU[T1SERVICE REQUEST F INVOICE <br /> S .orgy sR# y- 3 <br /> C-57' WC -WAIVE; C-57 Letter of Authors ro+r o sign pe mrt Encroachment doc_ 9/30/OZ <br /> TOTAL p 02 <br />