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170/29/2003 14.:56 2094_3433 FIFTH FLOOR PAGE 04 <br /> WELL PERMIT APPS !NATION FARM SITE,oAQUIN UNTY <br /> ENVIRONMENTAL HEALTH DpARTMENT (EHD) MITIGATION <br /> 304 E. Weber, Third Floor, St ckton, CA., 95202 UNIT IV <br /> (209) 468-34 9 <br /> NO •RF Nb LE i Mi FafP E5 A FR D i <br /> A aqu?n County <br /> is hereby made nt Stn Joaquin County far a parmlt to construct and/or install the Work described. This application is glade In corrtpliance with San <br /> Joaquin Cpun{y bevJopment Title,Chapter 9-1115.3 and IrEb <br /> the Stand Sof San Joaquin Counly Environments!tioalth bepartrnent <br /> WELL Location �'�'"'� Assessors <br /> �CroSS Street 1r ity � dip J �ca P <br /> PROPLR'IYOwner <br /> s.�,9j„ arcel#`Q -[��-p7� . <br /> _ ,,, kddress �lCQ City-f�4ap�i�Z 9i3 Phone# �i7 <br /> C•57 Contractor I f, <br /> Addres$_ S C � <br /> Consultant l Sub Cn ry 71p Ihone# �'r6 <br /> � �V___. •s �ress <br /> GIS Coordinates:X Y <br /> Township Range <br /> Section <br /> EA' <br /> ?NW�WrzE�pLIBORING (CP EOPR ,HYDROPUNCH,HMDAUGER,O H1=R•) d DfwSTRUCTIONSIL SOFiING# (choose type below) <br /> 104YEi # Il OVER-SOREw. DIAMETER <br /> 11*Other p PRESSURE GROUT <br /> COMMENTS; GROUT SPECIPICATI.ONS <br /> TYP �� S7 LLAT ON TY CO STRU ON ECIF CATI S <br /> NiTOF21AIG QI-tOW STEM DIA.OF E9t712EHOLE I <br /> [I EXTRACTION 11 AIR HAMMERIORIVEN CASING THICKNESS A-M IL L7iPLE CASINGS MULTI-LEVEL WELL CASING DIA: <br /> VAPOR -' TYrPEEOF CASING: I]STEEL VC Q MER: <br /> Q MUD ROTARY DEPTH OF GROUT SEAL tS " ` MIE TYPE TO 8E USED: <br /> *41R SPARGE:/OZONE RAI POINT(GP or CPT)GROUT SEAL PUMPEp e8 GERS fl I iOSE <br /> SO 11 BORING p HA1VD AUGER : Na _( OTE;MAXIMUM FREE-FALL DEPTH IS 30') <br /> OTHER GROUT SPECIFICATIONS <br /> —�� APPROX.BORING DEPTy — OLTED TRAPFIC BOX or [i STOVE PIPE <br /> CONDUCTOR CASING PROPOS b (if YES,I'rst specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE 1'3ORINGS REQUIRE ACCESS AGRE MENT OR ENCROACHMENT PERMITS, <br /> 48 WEORKING HOURS NOTICE REQUIRED I=OR INSPECTIONS. <br /> I hereby Certify that I have prepared this application and that the woj k will be done In accordance with San Joaquin <br /> County Ordinances, Ru s and Re atlons, and all applicable California State Laws. a <br /> Signed x o <br /> �Tode/CaMpanjr <br /> �r ��, <br /> Print Name s <br /> DEPARTMENT I NLY Date 1 <br /> SITE MAP IN;UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATI P>A_- <br /> aRpllCation Accepted sy <br /> 3rout Inspeon By Date <br /> c+ Issued C0ea- <br /> Elate Foal Insp <br /> destruction Inspeahon I#Y Date ction By Date <br /> :OMMENTs I CONp1TIONg; <br /> ACCOUNTING ONLY, AID# <br /> FAC## <br /> PE CODES FFE INFO AMOUNT REMITTED CHECI(# RECD 8Y' D <br /> PERMIT/SERVICE REQUEST# INVOICE <br /> 9 t S {,C. . 1� o SR# pQS� �. <br /> -57 WC -WAIVER, C-57 Letter of Authorization to si <br /> g Permit Encroochmerlt doc 9/30/02" <br />