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' 09/08/2004 11 :05 FAX 9166790 <br /> URS-SAGRAMENTO-GO . /6002/004 <br /> 0J:'2'S/2P1L14 114:24 2094683433 <br /> FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM ITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY E.HD) UNIT 1V <br /> ENVIRONMENTAL HEALTH 13EPARTfIIENTg52D2 <br /> 304 E.Weber, Third <br /> Fl 3449 or, ton, CA-, <br /> PI ES 1 Y PATES UED <br /> I.REFU GABLE PERM ffon <br /> a arlrnenL <br /> Errvironmental HeatthD P - A-5es:oes <br /> AppOr,Don Lc hereby made to San Joa4uin County for a Permit to mnsWct ondbr install the vrodc desmbed. This a hh 1p pa h made in Wmprianre with San <br /> Joaquin GountjDevelopmentTiue,Cho 1115 and tho Standards of Sam Joaquin County �1 �s^ ZJFarce?*. <br /> p GYO�g` > a^ Croys SUeet Lc^ 1 Gih <br /> L25 S-C 4 fUk 2e <br /> WcE•5LTL cLooncuaaUdooh�V_,�VV lY'e�J-g� i�sc l ,G• _X 1[rd� <br /> 006 r rt< .f��I[R <br /> P'PttPhDoFoonrn <br /> eue�s3 <br /> 2�0 <br /> 4t�__ 2-�LAddress / <br /> PROPCRTrr <br /> !yLavZAM m . <br /> /f\tCte 4yCGo11Ot , <br /> y Ow <br /> d secrMwTis�rt�— <br /> T ��C1S f:.rD• AtldfeaS -� <br /> C }��- Seef°n <br /> O°nsuluntl Sub Con7actor_ -- - Rarnpo <br /> Townehip�-� <br /> GIS C.mMlnate;: D�S•(RUGYION(rlloox 4'Pa Delav,•) <br /> oven-SORE, <br /> WORK TO BE PF..RFORMEO: D-AUGER OTHER-) U PRESSURE GROW <br /> O NEW WELL 1 BORING(CPT.GEOPROBE.HYDR03 NGH rHA� 5 <br /> �&CQIL BORING iF <br /> j)WELL# Grout SPerifcati°ns:� tt 215 <br /> -other. w �d l e o ole o tv <br /> "''` <br /> 00 TRIJCTION SPFCIFS8n2NS ,ES ONO WELLOASINGDMI <br /> TYPE OK WELL 1NcTALLATtON TYPE — MLLYIPLE CASINGS PVC (]OTHER:_ <br /> HOLLOW STEM DIA,Op BOREHOLE <br /> 11 MONITORING rl • CAS INGTHICKNESS_L- P OF GAS{NG: O o BE <br /> 0 <br /> D ty,TRACTION O AIR HAMMER47RIVEN TREMIETYPE 708E USED: a AUGERS Il HO', <br /> O MUD ROTARY DEPTH OF GROUT SEAL--�� <br /> O VAPOR GFOITr SEAL PUMPED; GYM D N° (NOTE:MAXIMUM FREE-FALL DEPTH IS 3: <br /> O AIR SPARGE O PUSH POINT GROUT SPECIFICATIONS[ STOVE PIPE <br /> HAND AD BOLTED•rRppFIC SOX or I] <br /> O(SDII BORING 0 AUGER APPROX.BORINGbEPYH��-(11 :S fstspecifcaIionshefe):� <br /> OTHER'.—_-- �r C 0 OTHER� <br /> ' O ONDUCTOR CASING PRQPO <br /> C., 0 r Lf 11 <br /> COMMENTS: .. <br /> REACCESSORE <br /> NOTE. 01 V NSPEUC R 4B WORKING I HOU S JN ADVANCE iFOROAA REOU RED INSPECTIONS. <br /> — -CALL UNIT <br /> 1 hereby certify that I have prepared this application and[cable Cthat the'a fcrn ailStatc Law'.e,done in accordance With San Joaquin <br /> and R ulati S,a all app — <br /> County Ord' C T,d��mpany �n _ Q - <br /> 1 _ X U'f <br /> Sgncd - Data — <br /> L <br /> o✓ USE ONLY <br /> Pdnl Name- DEPARTMEN - <br /> ss: <br /> as s . Che ��K�� <br /> SITE MAP IN UNIT IV FILE,AiDR3 O <br /> WORK PLAN DATED: 17 �E ° <br /> Data lssuod Oatc <br /> L.,rvt Final <br /> ppplienricn Accepted BYInspection By— " 1 � Dal � <br /> Grout lnspecuon ByAW-A LA 2.(. .0l n-S � C <br /> Dcsuuollan loapeclion By ' <br /> COMMENTS f CONO'T'ONS: <br /> C6 e <br /> ACCOUNTING ONLY: AID: rr15ERVICE REQUEST# INVOIC <br /> CHECK# RECO BY GATE PERM <br /> PE CODES FEE INFO pNIGUNT REMITTED '����5� <br /> - '0 �' I -Tst errnit—Fn�'oathment <br /> Leiter of Authorization to gn P <br /> C.57� WC,�WATYER� <br />