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WELL PERMIT APPLICATIO�9 FORMSITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT �, „I j <br /> ENVIRONMENTAL HEALTH DIVISION (PHS <br /> .EHD) <br /> 304 E.Weber, Thr Fl 468-3449 Stockton, CA ' 95202 MAY 0 9 2003 <br /> NO - EfUNOA6LE PERMrr EMPIRES R FR M D TE 15SUED �, I I CH T <br /> F d Sae <br /> 1ppllraGen ishereoy made Io San Joaquin County uin County Pvollc Health Services,Enwrwmen ess�,or'�G <br /> feta permit to construct andlor install the work described. This apDliwti°^Is medp ih 0, I <br /> y' i` I <br /> losquln County Development Tdle,Chapter 9.1115.3 andtne Standards It sort Joa u C Olty sty ID��,Pam6 <br /> ass 5�._Cross Sgeet 5'II-0c fos zj - <br /> (Phone# zo9 ` 000 <br /> NELLLocation 1 . (�I C r C;ty //aa <br /> ,�ri to rn u[h Address a,<ko �S7tflr Lie#71TSt NPnane#"l L4" <br /> PROPERTY Or^'ner_Ej 2 fl�.e I rc�cGty C ni Ao:.`�P <br /> L'. 7 AL( !� l dress i(� '1�c .-f.Sr O�.t� /�la:c � U�y379�i Phone# S3o - Y`(4= 3/00 <br /> C•57 Contractor / I c Q° CIry .Y1 <br /> ConsultantlSub Contrattar G GA rr, ter' Address - SectlonI <br /> TownsI --Rlange_r� <br /> GIS Cocrdinate �SVJOEILLLB#ORYG# rveGeroutfrSPWe'cG(T�ca�LGoll/riL/s�v:s '�[L)> <br /> t✓Y DEST�^R <br /> UC�tIOLNcQ3type <br /> �VEs i eb <br /> below) <br /> C3 e e�cce -. 5 choose <br /> WRT ® PERFORMEDROUNCH.HAND•AUGER.DTHE PRESSURE GROUT <br /> ? GC;4- � {cam ks <br /> 1.01her: <br /> WEBOR <br /> COM <br /> com <br /> r/ <br /> INSTALtAT10N TYPE CONSTRUCnON SPECIFICATIONS YES 1,NO WELL CASING DIA:a <br /> TYPE OF WELL ���J OLA,OF 5OREHO1E 4 t —MULTIPLE CASINGS. Q rn VC Q OTHER: <br /> ,fONITORING yWOLLOW STEM TYPEOFCASING: DSTEEL HOSE <br /> Q EXTRACTION QAIR HAMMER/ORIVEN CASING THGROUSS� / -rRFMIE TYPE TO BE USED: �E�UGERS D <br /> a MUD ROTARY DEPTH OF GROUT SEAL 1 eL No NOTE: MAXIMUM FREE-FALL DEPTH IS 30'� <br /> UVAPOR GROUT SEAL PUMPED: yes Q (NOTE: d d G t '( ,.,, fP <br /> Q AIR SPARGE Q PUSH POINT <br /> HAND AUGER GROUT SPECIFICATIONS: dD OLTEDTFIAFFICBOX or aSTOVE PIPE <br /> r <br /> Q SOIL EORING Q APPROX.BORING DEPI THS ,f YES,Iiat speeifice6ons here): <br /> Q OTHER: �1 OTHERS <br /> CASI <br /> CONDUCTORPROPOSEO4 <br /> ,-r �d �d.- — , <br /> 'COMMENTS: n C `` "`` t r~ <br /> ESS OR <br /> RI <br /> NOTE: OFFSITE HMENT F <br /> 48 WORKING HOU SCN A VANCEII OR ALLOT QU RED INSPECTS <br /> IONS. <br /> CALL THE UNIT IV INSPECTOR <br /> ceTti that 1 have prepared this application and that tha work will be done in accordance with San Joaquin <br /> 1 hereby fY linable California State Laws <br /> s,11 11 an Re ul tiorLs,and all app <br /> County Ord* Tde2ompany <br /> Signed a I <br /> Date , 7—D <br /> Print NameDEPARTMENT USE ONLY <br /> t � <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 16 p Area <br /> Date Issued Date S Z <br /> Application Accepted BY Date Final InsFen eY <br /> Grout Inspection By Data <br /> Destruction Inspection 13V <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# RECO gY DAT£ PERMIT I SERYIGE # INVOICE <br /> REOUESt <br /> PE CODES FEE INFO AMOUNT REMRT£D cHecK# (6 a 3 3 S <br /> sn l <br /> mD —+ ctt 9lz7 oc <br /> C-57_, WCC-WAIVER, C-57 Letter of Authorization to sign permit„Encrdachme+IT <br /> oc� <br /> FILE COPY <br />