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r <br /> WELL PERMIT APPLICATION FO-R'M SITE <br /> MITIGATION <br /> SAN JOAQU'IN COUNTY PUBLIC HEALTH SE VICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS,EHD) <br /> 304 E. 'Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 458-3449 G Rem O� <br /> PT <br /> NON-REFUNDABLE PERMIFF EXPMES 1 YEAR FFKQw[DATE;SSUED 2'. C <br /> A,pliczhiui is hereb=y.nide to peri,to cons-uct andlor instal"'-%e wont,described. This plication is made in complis^ce;with San <br /> ,)oZau,F1 COvnty Oeyelopment T iUe,Chcpter 1715.3 znd the Standar:.-c-f San Joaquin County Public Hx2aaA Servres,Environmental E:aaith Division. <br /> /' L D Assesear <br /> WCLt-Lucf(Jaticn ` C 03 ca-' �C� ,;ros5 Strect ,/ 4 V 1 p-Qcity -v Q a'`Zip Parcet;$ b�3 , �•�"YS <br /> Fl20t'1 PTY Osnner s�� �9 Add 55 L"� ` `��/� Cit} �l c Z�Q�Phone# 7�' fT7°v <br /> C-5?C��tractor �C [ Address He-'e--k4 Cltyjeo ww_ LiC: <br /> Consultant/Sub C3.tmvor AddreS_ 30 /e/xka'-4 Cit, 1cR PhcnPT7�' ' <br /> i <br /> CiS Cryo':-:atF-s-.X Y Township PangSect on_ <br /> WQRK TO CE FERC OF MED <br /> m IEvv WE'LL/6GR!NGGECPROBE. HYDROPU`:CH.HAND-AUGER,OTHER') i E�DESTRUCTi0N (chooso type below; <br /> 0 SOIL BORING ,.- i OVER-BOR1 <br /> # C./' - - j3 PR--SSURE GROUT <br /> cirther: Grout Sp'dfca Tars: ! <br /> COMM <br /> EitiTS <br /> ''VP-G OF WF-',L INSTALLA7,0N Tt'p_E CON STRJCTION SPECIFICATIONS <br /> 0 mOMTORING 0 H- LLOW STEM 01A.OF BOREHOLE Mlj4TIPL E CASiNps?.0 YES KNO tVELL CASING DIA; <br /> 0 E.K-,P?.CTION 0 A!R h?AMMEF DRIVEN CASING THICKNESS 'rYPE OF CA!§1NG- Q STEEL G PVC 0 OTHER: <br /> 1i+;POR ji MUD RO i"AFtY DiEP-H OF GROUT DEAL -TREMIE T"PE TO BE USEr0: a AUGERS KHOSE <br /> 1:AIR SPARGE PUSH POiINT GROUT SEAL PUM?Er-Ix"es 0 No NvTE: f4AXIMUfA FREE-FALL DEPTH IS 30') <br /> L'SOtL OORWO _� Q HAN7 AL G:n CRr-;QT SPE•=iF!CATIONS: <br /> c1?HER: Ce 7 07HER _ APPROX.BORING DEPTH S' tJ OLTEO TRAFFIC BOX or Q STOV=PIP= <br /> i <br /> CONDUCTdR CASING PROPOSED? (iYES,Cst speciflcat ons here;: <br /> I <br /> NOTE: OFF&TE BORINGS RI'EQUiRE ACCESS OR ENCR ACHMENT PERMITS. <br /> CALL THE UNIT rV !.4-PECTOR 48 WORKING HOURS IN ADV NCE FOR ALL REQUIRED INSPECTIONS. <br /> I <br /> I hereby ce,ify that i have prepar.d this applieation and that the work will be doliIe in aCCordance with San Joaquin <br /> County ordi n e Rules a Regulatians,and all applicable California State L_dws. <br /> Signed x Ts,ledCompau -'A'1-� .,�/� <br /> Rain;Name �C-EJ�� y C IDat2_ l��O�-B 0 <br /> DEPARTMENT USE ONLY i <br /> SITE MAP IN tlN7, IV'FILE,ADDRESS: Q Z <br /> WORK PLAN DATED'. 6-2-4--07— <br /> b?Fl aton Aopted B _ ---Date issued ! -0 Z Ares L-- <br /> Grout!nspecRan Ey _ Date_ Fina'Inspection By Data <br /> D�structon irisoRctior.By Date ! — <br /> �COMMENT, <br /> ,t CONDITIONS: _ <br /> I ACl Cc?'JtiTING ONt.Y: 1 k!Dr4 <br /> i, IRS CODES FEE tNFG j AMOUNT tZEMM- 0 CHECK# It41D BY DATA RWT t SERVICE REQUEST# IN-VOICE <br /> Z I_�2ABA J9031-0(oD _ <br /> C--37WC -V1�AT4'cR_ C-�7 }tet of Authci^;za ion+o sign permit Enc <br /> rQnchment doc� 9IZ1�0�` <br />