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01/03/2003 14:19 2094603433 FIFTH FLQDR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MMGATION <br /> E 1 8 203 ENVIRONMENTAL HEALTH DEPARTMENT(END) UNIT N <br /> 304 E Weber,Third Floor, Stockton, CA., 95202 <br /> (209) 468.3449 <br /> NGNUREMaNwAfEmmummm I nm mm pan W--UrD <br /> pin to heresy rr ad*man Sj=uts Courcy for a permit I*oendw arwar InoW Om work described. M appflr�tlan dr oarrA w Ban <br /> Joaquin Ceu*Deve[op.a ftTidtr.Ctopter$-11763 end the Slandsmis of San Joaquin om*arsvftmnwm Haab Depa*=11. <br /> WDLL Lecatiam <br /> _ IVF Rrsrir N Croce Soret AMoµAuT City SToc��+p -15 -PED, <br /> N N A <br /> NROPERT1fOsvnerti�`f.p�3ToC+ar. rJ 9?5.1v. �. �¢�+DaSTs y57 pro +lp$p ao4)937 B�'fl <br /> P, TLT�Ia Pltorl 9 ^Car tog <br /> C47Can�cLarCAsc 1•- wr��-addresa3to32 O�Ec C��&.r_G�y c�yA.�I ' iii� <br /> Car=mnt 1 Sub Cntr QEO-fP-C +S, (rJIC. 30 Pao se-&-r city �UrJ«7 „Phoned t��)e33-t fdoc� <br /> A{�V- D(Lrve• �. ONE �IVEJ�i <br /> 019 cmrdinatae:x .1r� .Tawnstdp N I4artge�sQ Seams <br /> MM TO BFPrERFOBM; <br /> U NEW WELL 1 BORING (CPT.GEOPRO6E.HYDROPUNCH,wa ckAUGE&OTHF; CTION (a mmetype ply" <br /> U <br /> BORING aEoi D URE GwLS <br /> ROUT <br /> ROUT PEFATIOSNOW C�• <br /> COMMENT S- [5u w idlV`1^L4 Min GFS' t�5S�P •w ��C � <br /> T, INSTALLATION TYi+E CONSM102"PPECmg <br /> p MONITORING ]]HOLLOW STEM DiA.OF BOREHOLE Q M1.IMPL.E CASINGS U MULTI-LEVEL WELL CASING DIA: �l <br /> Q EXTRACTION 0 AIR HAMMERIDAMEN CASLNO THICKINIESS TYPE OF CABINM O STEEL_ p PVC 0 OTHEFh <br /> 11 VAPOR p MUD ROTARY DEPTH aF OROilT SFAl TREMIE TYPE TO BE USED: GAUGERS p HOSE <br /> 11 AIR SPARM OZONE Q PUSH POINT(GP or CFn GROUT w-AL.Puww; Q Yas a No (NOTE: MAMMUM FREE-FALL DEM 18 30`) <br /> p SOIL SORNG a BAND AUGER GROUT SPEGFIGATIONP <br /> 0 OTLER;:`_____n OTHER APPF40X BORING OEPTi 1 a BOLTED TRAFFIC SOX w n STOVE P1RE <br /> CONDUCTOR CAMNG PMPOSED (if YE3,fiat speaftaftom in aortfene� <br /> CQ6IIMEN48s <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREFAENT OR ENCROACHMENT PERMITS. <br /> 48 WORIGNO HOUR.°NOTICE REGUliit M FOR INSPECTIONS. <br /> hereby cmft that i have Prepared this appl(cadon and that the work win be dome in a000rdance with San JcN3quln <br /> Cellnty Ordlnqmces,Rules pnpl�RequAftnv,and all applicable California State Lays. <br /> Pr6stNsnte Kim'I-E+ 0.gte Z�f'7 O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNrr IV FILE,AVORESS: /! / <br /> WORK PLAN FATED: e <br /> AXkv1an AmPW ev ` rate bmw 6-3 l <br /> Grout Irtgmcgon By i Date Final I _ <br /> De3trucion lrepec n By Ram <br /> COH1NlF M I CONDR50 <br /> ACCOUNTING OtiLY: AI011 FACy <br /> Ptd CODES FEE UIfFO AIdDNIT REMrtTED IGNE01(d RI:C'D 13T nATE PE RKM/GERiI=REQUE TO '.ri%== <br /> 50 p3 sR- ms <br /> t:-rv7„ VIIC�WAIVER C-57 Letter of Authorization to surf permit_Encs 9/x/02 <br /> s�o.�3r <br />