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07/31/2003 11 24 2094663433 FIFTH FLOOR PAGE 02 <br /> JUL-29-2003 09`23 •1BR1A • 1707 935 e <br /> WELL PERMIT APPLICATION FORM SM- - <br /> SAN JOAQUtN COUNTYMITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (END) UNIT !V <br /> e <br /> 4F- Weber, Third Floor, Stockton, CA., 95202 <br /> --iT— <br /> (2039) 46"449 O <br /> 1 EFtNfFT EXPIRE$1 M DATE <br /> NOTA-IFiFF11 Ilcation is made in compliance with San <br /> Applicatlon is hereby made to San Joaquin County fcr S permit to conatn<idt andlor Inaffi1I the world ro m��HsQlph Department <br /> Jaaqum County Development True.Chapter 8-1113 3 and the Standards of Son jonquin county Assam w 4�2 ES <br /> G(At�T. ross Street t I p� � <br /> { <br /> WELL Location = <br /> PROPERTY Owner 0 �" dreg. - Cdy b <br /> Aon <br /> C-57 ContraGtOr Addre49 <br /> uctt�,..p3(3-5 !� <br /> dd„w.e.Z�O Fcrk.tuks Clgr hW81 A- Lie# Phone <br /> ,607 <br /> Gor+suftunt f Sub Cntr <br /> a <br /> GIS Coordinadas- L�S ��01" M� 1�Z�}�Y M ,TowTownship, Range Seddon <br /> WORKTO BE PERFORMED, � DESTRUCTION (chQQSG type b8" <br /> gNEW WELL/BORING (CPT,GEOPROBF.f t�rDROPUNCl� IiAH[}-AUGEiq,OTHER ) a OVER-SORE DIAMETER <br /> Q SOIL BORING# Q PRESSURE GROUT <br /> l3 WELL# _ 11 _ GROUT SPlCIFI A PIONS <br /> t]�hrr 5tt- ra Q1+lc` S <br /> Comm �- 5 a Lo t <br /> TyI,EOFVY u jbi&LA IONTYPETYPE COtiS�RUCT1W P6CaFICATI S <br /> 11 MONITORING [�FOLLOW STEM D[IL OF BOREHOLE I]MULTIPLE CASINGS U MULTI-LEIIEI, WELL CASING p1A <br /> R EXTRACTION AIR HAMMEFWRIVEN CASING THICKNESS— 'TYPE OREO[u1�lE TYPETO BE USED d STEEL a PVC A OTHER <br /> [I HOSE <br /> 4 OR (1 MUD ROTARY DEPTH OF GFICUT SEA <br /> SPARGE/OZONE (]PUSH POINT(QP or CPT)15ROUT SEAL PUMPED []Yoe []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOiL BORING a HAND AUGER GROLrr SPECIFICATIONS CASING PROPOSED (13aLT� I p IG BOX <br /> CONDUCTOR <br /> UC'TQFi CAor d STOVE AISLE <br /> ,:KOTHER, C-� OTHER BOR ,f yES,list speaflcations in commOrit Saar+) <br /> COND <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE FIEGUIRED FOR INSPECTIONS. <br /> 1 hereby certify that i have prepaTed thIS appllcattlon and that the work will be done In accordance with San doequln <br /> County Of u and Regulations,and all applicable California State Laws. <br /> Signed x <br /> Titleloompany r bYI1 <br /> P001 name d EPARTMENT USE ONLY ata <br /> SITE MAP IN UNIT 1V FILE, ADDRS�: �Z� 6�3 <br /> WORK PLAN DATED: 2 '�� <br /> DateIsm uad <br /> Application Accepted <br /> •� •Z]3 e ��' <br /> SO <br /> Grout Inspection By Dale. Sna.1 Inspectlon By l3at <br /> W. <br /> Deetruckm lnspechon By 13a1a <br /> COMMENTS 1 CONDMIONS' <br /> ACCOUNTiN(3 ONLY AID# FAC# <br /> CODES FEEINFO AMOUNTREIArITPD CHECKA RECMKDATTE RERIUIITlSERVICEREOUIeS1t INVOICE <br /> Sj I -n Z.7. r' SR# tjp -7- <br /> C-57 WG i,-_t1' C-57 Letter of Authorization to sign permit �CTlcrnnchm It dor 9/30102 <br /> TOTAL P.02 <br />