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MPiY-20-2802 03:19P FROM: TD:1Q163834084 P:4/5 <br /> WCL <br /> L PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN J0.4QUIN COUNTY PUBLIC HEALTH SERVICES UNIT 1V <br /> HEALTH ALTH DIVISION (PHS-EHD) <br /> 304 I~.Weber, <br /> Third floor, Stockton, CA., 95202 <br /> (209)4e8-3449 <br /> WAS 11 ,21m, 1Z <br /> TNa ePPliadOn N made in eoraDiyna!'la'Say <br /> b OOrIfYUot erw1w Instep tt+er+ork deserlped. a,En�msntw Nevin DivNlon- <br /> Gon is henbY made tc s+n Joaquin County fer a of San Jepuln Cawmy Public H6910,Service Assessors <br /> to nt Ttde,CheO�r 0 1116.3 end the Start0er0! c>jt 22B Pa/ceR O I T-OR-C' <br /> baa�+tn County oeve ►e ki 960s Clty cs «! — <br /> ig N. a 1, 9q ��stne� <br /> NELL Laeatlon 44go t teoaa 2s CitY A�p 7 yzaa970 <br /> t•1.celwc'L les A�?sizCid���-ph°"et►� <br /> >RoPERSY Owner ew ) 3`m ra+tt �t. \A%1 3 s ovirz <br /> 9q.c % �,v�* fires <br /> C41Conerxior 23� %x City !?� <br /> ,7xtr g�R prz Aeon:»��— <br /> Consultant t 3ub Controdo 6 — Townl111P 4N Rir+9e 74f . <br /> Y <br /> GIS Coordnate°= <br /> p DESTRUCTIONa E bek�w) <br /> yyELL I BORING I Cp CMOPROGH,WDgMNCH.VIAND-AUGER.OTMER 1 �RESSVRE GROUT <br /> �L$OR�10r R <br /> p WELL X (grout$Veanca6ons= <br /> -Othen <br /> col <br /> E N I U TIPLE CASINGS?p 1'E9 d NO WELL CASING DWA <br /> TY i WELT, r" OW OF SORZ"OLE— EL PVC I1 OTMER <br /> Q ntOt+aITO/i1NC3 p HOLLOW STEM pVG T,{aCt(NESSi��T�rFE OF CASING: i]8TE Q HOSE <br /> Q EXTRACTION p AIR MJ►MMEFiIOR N Of PTH OF GROUT SEAL,�,_.�.—*R IE TYP6i TOM USS p AUCiDE 0 <br /> Q p WUD ROTARY SEAL PUMPH0. Y� 0 No (NOTE:M/�1MUM L REE-FAEL DEPTH lS 30') <br /> Q NR SPAIt4E Q PUSH POINT STOVL PIPE <br /> GROUT SpgCIfaCATIONb: a Sp�,�D TRAFFIC DOX at p <br /> Q SOL BORING p HMO AUGER NG DEPTH <br /> O�THER,��—�•— APPROX.BORt �N YES.listt�d��^a <br /> herex <br /> p OTHEa--- _a CONOUCTOR CASING rItOPOSED?_�_ <br /> -COMMENTS: <br /> - OFFSITE sORINOS REQUIRE ACCESS"-O.-"-R <br /> EN oROAL <br /> `R� Reo Ns ECTIONs. <br /> NOTE. <br /> CALL UNIT IV I CTOR 46 WORKING HOURS IN ADVAN <br /> kation and that the wtarkwl <br /> I h at 1 hirel be done in pccordanca with San jpaqui <br /> rad this aPpl <br /> Co pI'dl ces, 1 RQgulaUont:,and oN altpplicable CaliforniaCailfofnia State Laws. - <br /> TWerGor'Pany w»aicl� et: wsywwr; <br /> A Data S-7n X02 <br /> Sb <br /> Ponta '� DEPAR i nliCn I US>~ NL <br /> Srrg MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> C`c Oak issued Dam <br /> A oNoon ACOPW DsM Incl Inspection By <br /> Great Inw6cw by De <br /> Dorado"M <br /> COMMENTS!CONDffIONS: <br /> ACCOUNTING ONLY: AV G' Y OATS <br /> PERMrr/69RME 90 � INVOICE <br /> PIE COM Fee INpo AIMOUNTRIMIT"o cHECt(t< <br /> ^cr-10othment doe—, 91 <br />