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06/24/2003 16 19 2094683433 FIFTH FLOOD PAGE 02 <br /> WEL PERMIT APPLICATION FG. .,,X UwiTW <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIFtf?WEPt AL HEALTttDIItMKM(PP ENDt <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 " <br /> +t20'gX 9 <br /> NON-RE-FUNDABLE PERMIT EXPIRES 1 EAR FROM DATE ISSVEO <br /> ApphCalton is hereby made to San Joaquin Goautty for a_pe[mtLt&C4U1%t = aad/t¢-3tall the walk dawaLba Tbie e..pLg4.m ,.^ 1�`h <br /> SA= '03Qwu County-Deivolopment Title-ChepW94115 Sand-the Standard0 of San Joaquin E ter....,EnV11' <ticampparua,y <br /> orrntyrPr�trcHcalth-5ervrces,ErtvrrcmrtentathteatttrBmsmn, <br /> Wal Lacavo • ASaeSaOra �1 <br /> cluzz ttitp' -2111 ParcBtlt ! -� <br /> PROPERTY Owner&WG1[ Addne6S n Ctty�fQt�tdVi�" ro� �APhnrte� /��j A <br /> C 57 COniraClo iY ddress 0 Q 1161 CityQ Zip �Lid1 ( Phanei#l`i 3l3-Sg�D <br /> t:ttl6Ult7rrf/3uh-CarrtraCto 1 "'..� .� J�_r pdres�8r�60td(rw 1opll.,�u L�Crt <br /> Ge Co.Co.to.,ate? X Y_ _ Tewnsh+P Flange SeUton <br /> WORK TO BE PERFORMED <br /> (MPxViTLL)BORWO-f CIaT GE{WROBS ti'' DROPW4614-H rNB- 1d6EF+,Pf <br /> l 11!R-) p C1ESTRuctr0rriclrvu3v <br /> a SOIL BORING# 11 OVER-BORE <br /> 'Other *ELL*__4_- - 11 PRESSURE GROUT <br /> COMMENTS <br /> TYPE or WoM INS ALLAYTCYN TYRE CONSTKOCTfON SPECIFFCATrQNfL <br /> JtZON1TORlOLLOW STEM DIA OF BOREHOLE r MULTIPLE CASINGS'?Q YES�O WELL CASING DNA Z`t <br /> 0 EXTRACTIM19N QAIR HAMMER/DRIVEN- CAStNIiTHICKN B TYPE OF CASING <br /> Q STEEL JKVC 0 OTHER- <br /> 0 <br /> THER-Q VAPOR —� �o MUD ROTARY DEPTH OF GROUT SEAL 50r TREMTE TYPE TO BE USED a AUGERS 'HOSE <br /> 0 AIF SPAR Ta/ d PUSH POINT t ROI IT SEALPI'M �__. p No-(NOTE_MAXIMUM FREE-FALL DEPT 3Q_� <br /> f l <br /> SOIL 60p HAND AUGER APPFiOX 80RING DEPTH_ � r kfiOLTED TRAFFIC BOX or p STOVE PIPE <br /> •THER C z_ a OTHER CAAi04}CT S£p� 4(, YES list specifications here} <br /> COMMENT <br /> w <br /> NATE- OFFSME B0Rr1Nr.&REQUtRE ACCESS OR EMR-OACHMENT PERMITS- <br /> I hereby t enify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances State Laws and Rules <br /> and Regulations of the San Joaquin County heart__e..d arnt s4ainature-cWtes TheUaUown 1 eeeldy-&hat ars the puiacmance oftimwask, <br /> for which this permit is issued,1$half►rot employpersorrs subject to WORKERS'COMPENSATION Laws of Cafrfamia" Contractefs hiring or sub- <br /> eanhZCtInq srgrratUWCerttftds the forlowmg-T CTHOY M11twVWPVrftrMWTCV at`thT worn 1 br which-ftS permd is issued, I shall employ persons subject tq <br /> WORKERS COMPENSATION Laws of Califomfa " <br /> TIJ AaLT AdLtSY-- _ _' R�eQWRI�D INSPE TKMS1 <br /> Signed x Tltfe .G. S 3 t} flare <br /> SEE SITE MAP IIS UNIT N WORK PLAN DATED' 07 <br /> DEPARTMENT USE ONLY <br /> ApO aeon Accepted By 't r Date-Issued ro 1-Z,4-14-3 <br /> Grout Inspadton By pate Final Inspection By Date <br /> Destruction Inspeetttyn By Dare <br /> COMMENTS i CONDITIONS r v n ,r;,"L <br /> ACCOUNTfNG"ONLY AIDS <br /> FA C-4 <br /> PEEg FEE <br /> tlIEO AMa1JhlT BEKMEQ_ CAECK 11- RECt2aY Oaxr_ PERAUT/ s urvnrrc <br /> 35o I 8`r. oU 84 0 0 !JD 3 +321 <br /> ' <br />