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OCT-28-2003 16:15 FROM:PRECISION —IMPLING 510 237 4574 - TO:-10 G63 41 <br /> IU!Y//Ua alln 1J:[I6 bAA DIU CC IDu t,rUalA1R1A U LA�vy -L ��"ILT <br /> CWT <br /> ��� n� LF�7- <br /> WELL PERMIT APPLICATION FORM SITE <br /> I' �'� IU) SAN JOAQUIN COUNTY MITIGATION <br /> OCT 3 ENVIRONMENTAL HEALTH DEPARTMENT(EHO) UNIT IV <br /> 2003 304 E- Weber,Third Floor, Stockton, CA.,95202 <br /> ENVIRUi1iMENT HEALTH (209) 468-344,9A O . G <br /> PERMIT/SERVIC,E 111111 FU AB LEPERIAITF.XPIR 61YF�FROJaDATEISSUED <br /> Appikation Is hereby made to San Oaquin County fora m+it In coratuct and/or Inoun county Enrilonmae talhHeis aAih Dopartrnent plication is de in Compliance wish San <br /> Joaquin County Dovelopment Tllte,Chapter 9-1115.8 and the Standards d Son Joeq Assessors <br /> n� .-ZP <br /> WELLLocs[I6Ro.S so�f.a aC-AJ�'�t ''D Gnyss Street �+ 935— a-13y 3 <br /> �� <br /> PROPERTY OwnmrSr �ry_ <br /> City <br /> C-57 Contrdclar = �"�5°�^`�I ^ AdefklSS <br /> ;�1, IpLic�+Gnoneu��` a13�'-`iS � <br /> i aTi'l- Ss��6 6 3 •+,o� <br /> Consultan[/SubCntr .�'�r"�r <br /> � Addre 5& FJ�CIry 0 1C1r.a L iCff _Phoneft <br /> GtS CoordiNtaS:X--- ' <br /> Y Tcv_!$hlp Ranga <br /> X41 T05 FORM <br /> _. [ -� oto[]�ue� + <br /> c t)elow) <br /> O • UGERH <br /> NEWWBEHYDROPUNCNHANDRRDMETqESO[L BORINGY PRESSURE GROUT <br /> Q ELL 0 ppOUT SPECIFICATIONS - <br /> p-other <br /> COMMENTS: ��• �nFG y`-TQ ,� �eJr, 3 <br /> atP WELL INSTALLATION M& CONSTAUCTION BPECI0Q9TIt M <br /> lA <br /> (7 MONITORING (]HOLLOW S'T'EM DLA.OF BOREHOLE (f <br /> MUI_TtpLE CASINGS 0 MULTI LEVEL WELL CASING DIA'_L'— <br /> U EXTRACTION 0 AIR HAMMEWDRIVEN CASING THICKNESS- /`t „T FIE OF CASING: 0 STEEL O PVC []OTHER: r OSE <br /> VAPOR o MUD ROTARY DEPTH OF GROUT 15EA1'�a!AL aikP�# TREMIE TYPE TO BE USED: I]AUGER$ ( <br /> []AIR 3PARGFJ OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED:a$.res o No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING C]HAND AUGER GROUT SPEGIRCATIONS <br /> [OTHER —(]OTHER APPROX BORING DEPTt-+AA' : 1� ---& U BOLTED TRAFFIC BOX ar 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED I,IA ._(1, YES,list specificatipna in comment Becton) <br /> coMMErrrs.,,_ - - <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, Rules and Regulations,and all applicable California State Laws. <br /> Signed <br /> - r Titla/CompanY� `"4� �jC•G.T�iS� — <br /> I 41L—L,� <br /> Prinl Name_,__ DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 5 <br /> WORK PLAN DATED: <br /> l _ . <br /> Appllromuon Accepted BY Dale Issued Ar9d <br /> ,� :.� , <br /> Gut Inspection ey _ <br /> Oatv" Final hrspecian Dy Dale (l <br /> Da=cGon Inspection By Dab <br /> COMMENTS I CONDMQNS:, <br /> ACC:::�OUNTING ONLY: AID# FACT <br /> PE CODES FEE IWO AMOUNT <br /> REMrT TEP CHECK fl RECD BY DATE ' D6RMIT/gERVICE REpUPST 1F INVOICE <br /> Z�ol tor31 SR# 3lpo �3 <br /> C'57, WC____,-WAIVER_ C-57 Letter of Authorimtlon tO Sign perMit_Encroachment doc_ 9/30J02 <br />