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01/09/2003 15 38 2094683433 FIFTH FLOOR PAGE 03 <br /> 12/27/2002 14,34 20946B3,-^ FIFTH FLOOR PAGE 04 <br />' WELL PERMIT APPLICATION FORM r r <br /> SiTE <br /> SAN JOa QUIN COUNTY MMGATION <br /> ENVIRONMENTAL WEALTH DEPARTMENT(END) UNIT IV <br /> 304 E. Weber, Third Flog, Stockton, CA., 95202 <br />' (209) 468.3449 <br /> fitON4ZEFUNDABLE P T EXPIRps 1'M9K a ATE ISSUER <br /> Appticatlon fS hett5bycrrzde to$d11 Joaquin C`wnty for a permit to eahuN ct and or mslall Ze work descnbed This appfiwt3an is made,n epmplianve With San <br /> Jaiquln Gaunty Dev6IQpMerrtTiCe,Chapter g«411S_3 end the Standards of SanlJoaq++wn County Envlr*nmarJal Haalth Depart�r enL <br /> WELL L4Cafian� t Street-10C_J�Ors Cray p �,r31�Farael#�& <br /> Pitdi gm-ryownttr_.��?c ai�Pne,��, rj _AddreSC P.6.60X7ZEEIg� t�Y rip�.��Phane# _ <br />' C47 Gonvaetnl ` ` dress A�/� ,s-_ p � <br /> 7�+iTo!AJ� /'toil C�typML-Imi uar Phon9#,ZLE213'"ad:0 <br /> CnnsultairAl Sub qtr 2gA Adm G1U"'g - <br /> h <br /> GIS Conreinates'K. . Y ,Township Range Section <br />' WORK TO BE 1KXF0WE0- <br /> WNEW WELL f BORJNG(CPT,GEOPROBE,MyDROFUNCH,K M[)AUGER,OTHER.") IJ DESTRUCTION(Choose type bobby) <br /> R SO)L BORING# <br /> ELL pv 13 OVER-BORE <br />' •other # ° Grout Sperifirabarrs 11 PREWURE GROUT <br /> COMMENTS <br /> 'FyP9 PE WELL INSTALL4TION TYPE CONSTRUCTION 8eggE!g&M N5 <br /> MONITORING VH1L/Q1nr STEM DIA QF80REHOLEQ EXTRACYfOhf V' MULTIPLECASINGS?QYESAt40 WE.L CASING DIA;rr•IJ HAM MERORNEN CASING THJCKNE'SSS�+ TYPE OF CASINO, G STEEL APVC U OTHER. <br /> &APSOR 0 MUD ROTARY DEPTH OF:GROUiSEAL JD`-,r ' -TREMIETYPETOSEUSED' flAUGERS ORR <br /> RFARGe Q PUSH F�OINT GROUT SEAL PUMPED, ra yao XNa� (NOTE' MAMMUM FREE-FALL DEPT 30') <br /> :OIL BORING ll NAIAD AUGM GROUT SPECIPICATIOms #w;!LNj' ( r J fr % <br /> 9 OTHER„T n OTHER APPROX BORING DEPTH =`�QLTED TRgpF1C SOX or Q STOVp <br /> rlye <br /> I 'COMb1EN't''S CONDUCTOR CASING PROPOSED? WO (if YES list epecificntions hero)- <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> ICALL THE UNIT IV INSPECTOR 48 WORKJNG HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work%nil be done in aeaerdance with San Joaquin <br /> County O Inances,4RUIe&and ft3ut2 *"S,and aIJ applicable Culdomla State Laws. <br /> 'aigneG TrdelCompany <br /> 'nnt Name <br /> DEPARTMENTUSE ONLY r5� <br /> 3IrE MAIC IN ulvrr IV FILE,ADDRESS: <br /> NORK PLAN DATED: rY} 11 <br /> %pplicatlon Accepted By ate Issue <br /> DrorA Inspechon 8y !b Anal Inspeo4on BY Date <br /> )eslruction lnspec.Oon By Date <br /> XWMENTS I CONDITIONS <br /> I ACCOUNTING ONLY Alps <br /> Car,* <br /> cOnES Pf=E IIVFa SUNT REmrmD CHEcx# REC'DBY DATE P9KMrrJ SEWGP-RILQUEST p alva3GB <br /> 0 Jr SR# Z342? <br /> =" WC -WATVI=R C-57 Leihsr of Autho sign permit Itncroachtnent do4— 1/25/02 <br /> i <br />