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01/03/2003 14:18 2094683433 FIFTH FLOOR PAGE 02 <br /> �, WELL PERMIT APPLICATION FORAM S1Tr <br /> SAN JOAQUIN COUNTY pM'1`ii3ATION <br /> FEB 1 8 2003 ENVIRONMENTAL HEALTH DEPARTMENT(END) UNITN <br /> 304 E.Weber,Third Floor, Stockton, CA., 85202 <br /> (209)458-3449 <br /> I YEAR-MM RAM MIJFD <br /> Appy+Is he"mdo to San Joaquin County for a perm$Ao oonstrud wdkr tnsW dm wart dasotlbad- T?ft aW=ttan la made h=mpUem vilh Sm <br /> Joaquin County DwelopmoUTIft Chapter 9-111"and itis famdards of San Joaquin 09aa+ty amkotone W Health <br /> DepwftmtL <br /> wpL.L L mmuon 1111 Av y Dgiow Cross sbmt,4RSbrJ a U T qty S TxlcTo rel zIp�S Z AVOW=�D3.2�oDo� <br /> t+•�x r155to 55� �#$lo-2310 <br /> PROPERTYa, r Fa R M S dn3sa a2 N. v E <br /> RAuc.to <br /> 742 57�r ro p�,�C9r rag -!!m9 <br /> c•D7cordraetarCAscA� DR',c�.aw6.Addresa3fa$2 4M 6C C�aerr� ClsycattowA �p��[�5- - <br /> ulmnrlsub cntr Gg0TAAr_% I C- r se3U-as PaAg F'CT city gip- wes-7 9Pi t art C9tso��53�teoo <br /> P <br /> 41a Cmmmratm x .Y Tavnshlp Iigltge�Q seo�an 1�arUi �1VE� <br /> VNM To RF omeA_RN[BQ: <br /> p NEIN WELL BORING (car.GSOPROW,HYDROPUNCH.HAND-AUGM Onffli`) <br /> n. <br /> Diw <br /> ON p ) <br /> d SOILBORING �WCVER!4agE <br /> 0LE GROUT <br /> av)u <br /> m-wrIc=oNs MEAT CEMEN T <br /> COMMENTS- , eeR-e oee m%&-4LO,,,35�1�5 A+�►d MW-5 'ria e/ '1345 Li r rm 12 � Au66,LS_• <br /> W LL ARwE C k7 <br /> . RQU31-t+ &YP t WC w 1311 N G` R►a�T�T <br /> INU 11A MM C-m—m SMM ATia'I�S <br /> d MONrI-CRtN4 to HOLLOW STEM DtA.OF BOREHOLE a MULTIPLE CA51NGS a MULT14.6VEL WELL CASING DIA: <br /> D DRRACnON 0 AIR HAMMERMRRIEN CASNO THICKNEW , �TYPE OF CASING: a WMEL o PVC 0 OTHEM <br /> II VAPOR (]MUD ROTARY DEPTH OF GROUT WAL. TREI&E TYPE TO BE UB8D'- IZ ALMERS 0 HOSE 5� <br /> if AIR SPARGt>r!OZONE p PUSH POINT(GP or CPT)GROUT SEAL Puw-, : Q Yes p No (NOTE AEA)411i1UM FREE-FALL DEM IS 301 <br /> ll SOIL BORING a HAND AUGER GOUT SPECIFIwilomm <br /> p OTMER a OTHER APPROX BORING DOrM d BOLTED TRAFFIC BOX or d STOVE PIPE <br /> CONDUCTOR DAMNS PROPOSED Of YM Ust¢podflstform In ammmeetsmoan) <br /> COMMMM• <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AOREEMF-NT OR ENCROACHMENT PERMITS, <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared thlS arpllcadon and that the work will ba done In accordance with San Joaquin <br /> County Ordl r.�s,Rules and Regutat aM and all applicable California�`e Lows. /� T <br /> Sis and x `-'� Tttlaroomgany r.►_ �� r G76C l n1S <br /> Prat Naas P Oat -- <br /> DEPA ENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,Ar � -5� <br /> WORK PLAN 13ATED:, 2 d3 <br /> AppI%z*m A=pren ay Data Im3d �- f _ Araa f`a�at <br /> Groin Inep9011on nay mal I Dam <br /> Desauetion lnapedbn By 1 AI <br /> 0=19m B r OaNrrn0NS• Tom_ff <br /> ACCOUNTING ONLY: AICW FACR <br /> PE COD595 PEE[WO ANIOUNT RIMIn TED CHECK* RECD BY DATE POWT f GMWE RIUEUr Q <br /> d-? zrI 3 s" j Q <br /> C-57 WC,;WAIVEI,_ C-57 Letter of Authar(ZeItlon to Sign permit Encraachrnent eine 9/30102 <br /> SR D <br /> 0 3993e <br />