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02/16/2005 15: 28 2894683433 FIFTH FLOM PAGE 01 <br /> WELL PERMIT APPLICATION FORM SITE <br />' SAN JoAQUIN COUNTY `- MITIGATION <br /> • UNIT lV <br /> ENVIRQNMENTAL HEALTH DEPARTMENT (EHO) <br /> 304 E.Weber, Third Floor, Stockton, CA., 93202 <br />' (209) 468-3449 <br /> NUN-Rg UNLDMLE PERM"SPIRE6I 791311 FROM DATE IS U99 <br />' Applicatloa is hereby made to San Joaquin County for a Permit to oonatruct and/or Inutdi th0 W*tk desodbed. This appifomtion Is made In mmp4ianoa with San <br /> Joaquin County Developrnant Title.Chapter 9-11152 and the Stw4erda of San Jodquin County Entirgnmental Health Department <br /> WELL l.oeallan rose streett.- +pia r <br />' PROPSRTYOwnar Zjj_,dj*jUt dross �1►'• �r dy'� .GitY P2 ha s# 1ITL iff,Z " <br /> C47 CorrtrdCtor <br /> y� <br /> cansulttrrtrSub taantrac6a A-` adaresa AWAy <br />' GTS Coordinates:X` —,Y,_ Township Rangv Secllon <br /> W WELL IBORING(57,GEOPROBE,HYDROPUN H.11AND.A GER.OTHER') 10 DESTRUCTION(ch4088 typo b0l*W) <br />' *WIL 50AING# — -- OVER-301112 <br /> a WELL# PRESSURE GROUT <br /> •Other. firout Spoalfiaallons <br />' COMMENTS: <br /> =E OF WDLL INTALLATl 7YPii= <br /> [I MONITORING p HOLLOW STEIN DIA.OF BOREHOLE —p YES LINO WELL CASING DIA: _ <br /> D EXTRACTION p WR HAMMERIDRiVCN CASING THICKNESS�_i'YPE OF CASING: Q STEEL 13PVG 0 0THEIR� <br />' 9 VAPOR a LAUD ROTARY DEPTH OF GROUT BEAL_Zp _TREMIE TYPE TO 6E USED: 0 AUGER$ Il HOSE <br /> p AIR twrsrs .PUSH POINT GROVT SEAL PUMFF&D: a Yee ,V410 (NOT'IE: MA)UMUM FREE-FALL DEPTH IS 30') <br /> j"011.BORING p KANO AUGER GROUT SPECIFICATIONS. C�jr.! -- 4C - <br />' a OTHER: OTHER_ APPROYL BORING DEPTH /T .# _0 BOLTED TRAPF'IC a0X or n STOVE PIPE <br /> CONDO TOR CA.SIN ROPOSED? (If Yes,Gat speclacatans here <br /> 'Ct7lIrIMEN r$ j��P� .�► <br />' 6 < <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> GALLTHE UNIT IV INSPECTOR 48 WORKING HOUR IN ADVANCE FOR ALL REQUIRED INSPECTIONS. % <br /> I hereby certify that 1 have prepared thlS 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 Tt#fe/t„prtpany * r <br />' w Date ! <br /> Print Name <br /> DEPARTMENT USE ONl.Y. Or <br />' SITE MAP IN UNIT W FILE,ADDRESS. <br /> WORK PLAN DATED: )� � <br />' Application Aeurpted 8y..i:,�o ��. .._Date issu f <br /> Grout Inspection By Date Ftnal Inspection 15y Date------ � <br /> Destruction Inspection By Data <br />' COMM NTStovNOMONs: <br /> AC=:NTIN00NLY: AIOp ,rbr,„ <br />' PB CODE$ FE£/NFO AMOUNT RSIAnTEt7 CHECK# REC"G 6Y PATE PERMIT i ISLRYICE REa1]I=sTsi itiVCiC9 <br /> C-57— WC 7WAIVEk C-57 letter of Authorization to sign perm/# Encroachment doe 1�251Oi <br /> 1 <br /> 1 <br />