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07/09/2003 10:34 209-579-2225 M=ESTO ATC PAGE 02 <br /> r, <br /> WELL PERMIT APPLICATION FORM SITE <br /> }yl1T1GAT10N <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT fV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> E�dVIRGPdP,'iEi�lT HEA'_TH 304 E.Weber,Third Floor, Stockton, CA., 95242 <br /> pE�;�91TiSER�ICES (208) 468-3449 <br /> tip <br /> ir.R _ _ The work deSCribed. 7his 2; <br /> Joaquin w is <br /> h Devi rrads opment San Tilts joactAm r 8-iLL113.3rand 7rs7as Standards of San Joequui�nstrud an l CCoLx*p blit Mealtn Services Ernironmentat Mit Ith Division <br /> -pan <br /> Assessor's <br /> ar - CrosaStme��Clty-��� Pen��,� <br /> WELL Load*n l a Q 7 <br /> PROPERTY Ow"rgZA, OLJ _. d PO Rhe Cr,�d yy�� C>1Y�DD non <br /> C-P Contracnr— <br /> �7 Addraa 4o'I 1.1,.a_�a_. � CItYL'...:�•IIPY�. Ph�, S <br /> Consultant I Sub Contrador <br /> GIS Oorxdselatss:X Y <br /> TawneRlp Rates 9eotlor� — <br /> Q DESTRUC'1ON(�+oose tyvabatgy).. <br /> yE svE Y WELL!BORING C GEOPROBE,MYDROPUNCH.HANQ AUGER.CT1iEA'� a ODER 80R'e <br /> &•SOIL BORING e G PT-I 0 PRESSURE GROUT <br /> 0 vie"0 Grout Spsdllwtlone <br /> 'GMsr. <br /> COMMENTS: <br /> TYPE G V+1ELL 13ST t L aTION TYPE c•ON9TrdiCTICN SE&QE SAM= NO WyrzS f L CASING OIA <br /> u MONITORING 0 HOLLOW <br /> M�STEM <br /> RIYEN CASWG THICKNESS /f/� __ INC <br /> DIA.OF SOREMOLSTT�E OF�CASING�0 EL 0 pvC 0 OTHER <br /> 0 EX7RAC710N Q �' TREWE TYPE TO BE USED: 0 ALGSRS Q HOSE <br /> Q VAPOR Q LAUD ROTARY DEPTH OF GROUT 6EA11 <br /> pAIRSPARGE .-8-*vs>{FOIIVT <br /> GROUT SEAL PUMPED: dYee ONo (NOTE: MN(IMUM FREE-FALL DEPTH 1330') <br /> ILSORING Q HA,NO AUGER GROUT 9TECIFiCAT10N$: /U <br /> 60THER: a OTHER APPRm BORING CEP TH /J � 0 BOL,EO TRAFFIC ons or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSFI t �tJd __t u`�-`s•�a�°nwt�e Mnr <br /> 'COMMENTS: <br /> NOTE: OFFSITE SORINGS REQUIRE ACCESS OR ENCROACHMENT <br /> FOR ALL ME REP PERMITS- <br /> CALL THE UNIT IV INSPECTOR 44 WORKING HOURS IN ADVANCE <br /> ONS- <br /> I haraby eartify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances IS an Suiatlons,and ell applicable Callfomis Stats Law$. �l u <br /> $14 nod x Osis 719 <br /> Print Name DEPARTMENT S O Y <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> G e n.e. .d 2 Aru <br /> Avg kmdon Aoosptod By u~u trove n 6y Ca>. <br /> GmcA lnspsean By oats <br /> Castnujon Ins action N <br /> COMMEuTs i CONDrr-oN3• a <br /> ACCOUNTING ONLY; A1CIF - <br /> FIR CODES Paz INFO AMOUNT1 E ..TEC '0 CNECKV A CY �I►Tt <br /> flRMIT/SERVICERECUIRSTe <br /> INVOICE <br /> I t- <br /> 0 8`i . i c) 12 l �� SRO 3 <br /> C-07_ WCC WAIVER, C-57 Lctter of Aut i Io to sign,permit!Encroachment doe- <br /> 9/2T�00 <br /> Z aE <br /> 0026 13C83SH-1 dH WdSb c 1 Econ so inn <br />