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WELL kRMIT APPLICATION FOkA <br /> SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> EW4RONWNTAL HEALTH DEPA'I WNT (EMD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA; 95202 — ~. <br /> (209) 458-3448 <br /> Wkslm is needy mmde la San Jammin CuLm*tog a pw*1*aww* ct snftr tneWl Me work v1sscrbo. T t.applmfoe K mads In compo nce with son <br /> biquin C*wtY Development Tills.Chapier 9-111 OF 3&W#*'Sbndwft oCounty <br /> VE.L 1«afion cross street r <br /> Sc+Je N% Vit t <br /> 'ROPEM owner "0110 % <br /> may 1,.u,ers _ +rye._ �Y ..�'`a c r i.v as&L <br /> :.57 c4mmdw <br /> :ordmmftk/sun CanaadorAddass <br /> jZ <br /> leu t�7 tic� Lla1P� 7 Peons ._Y6 7/ Q G <br /> Caoidnie:X Y Townswp Ronpe Sedbn <br /> AMW WELL/BORING(CPT.mGEOPROBE,BUNCH,HAND-AUGER.OniEtt*) Q DESTRUCTION(dmm to We" <br /> _Q SIL.90RING It <br /> E�. Q OVER430RE <br /> OIMar. Q PRESSURE GROUT <br /> Griaut.Spex <br /> :OA�AENTS: <br /> WE OF.WELL WTALL.ATWH <br /> XWWORING >4>40=ml� <br /> STEM DIA.OF EHOL.E MULTIPLE CASINGS?AYES WELL CASING 01A: .r <br /> I EA(VCXTRACTION Q AIR CASING THICKNESS_ TYPE OF CASING: a SEEM <br /> I VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREAME TYPE TO BE USED: , � U�GERS . Q HOSE <br /> I AUR SPARGE; it PUSH POINT MW SEAL PUMPM a Yss Alo Ihr UM FREE# LL 00"I$301 <br /> I sol.BORING 11 HAND AUGER GROUT SPECIFICATIQNS: c n l IASS UAW <br /> I OTHER:_________A OTHER APPROX.BORING DEPTH 2 . LTw TRAFM BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?_/V0 (if YES.1*apecipcallons hwe):. <br /> I�lNi'a: <br /> NQS,: QFFS#E,B_QRlNGS.WQUft ACCESS OR ENCROACHMONT P"ERWS. <br /> CAUL'TSE`UI T tY WMEC 1 -48 WOrd(I G HOUM IN ADVANM FOR ALL R1MMM M11$PECTIEONS. <br /> hEwbY ON WY that 1 haw prepared this application and that the work will be done in accordance with San Joaquin <br /> :otlnty OIV77 Rules and Revulations,and all applicable Cali[ornle State LAw& d <br /> Owl k- <br /> 2-7/02— <br /> Tttle/Campany � �I <br /> ri<,t Nome I Dan 'i�0 <br /> MUMMYDINZAR � <br /> ITE YAP N UNIT IV FLE, nPLAN _W <br /> VOW DATED' Jar 00 <br /> ppkMm A=pInd BY Issued <br /> lout ahp.dlarf By- V Da1e F1rw1>napedlon.ey Dile <br /> e0udfon Inspedfan Die <br /> 01111mm I CONDmON& <br /> ACCOUNTING ONLY: AID# <br /> C4P`! <br /> PE CONES FEE MFC AMOUNTR0■1TEO CHECK NI RECO BY DATE PERMIT/SERVICE Ii�Ep1IEST# INVOICE <br /> r g 1.1 .%--36' <br /> -57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroac>hmad doe IM/02 <br />