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01/23/2003 09 44 2094683433 FIFTH FLOOR PAGE 03 <br /> Jan 23 03 09. 03a Ft xzen Env- Inc 9if 933 2i72 r•3 <br /> 1711t3!2303 P18 31 209 433 FIC Til Ft OCR <br /> �L <br /> 4 LLr,l V , WELL PERMIT APPLICATION FORM SITE v+ <br /> JAN 1 6 1003 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENT HALTH ENVIRONMENTAL HEALTH DEPARTMENT (F-HO) UNIT IV <br /> PERMrT/sERVICE$ 304 E.Weber, Third Floor. Stockton, CA , 95202 <br /> (249)458,449 N <br /> PION R ND PE 7 ERPI S I Y EZtO CATt3 5SUE0 <br /> ADCIICa1,on d herecy='nada to San t(I arum Cay ty Dec a�uTli'In camif."arwor Install(i1e W01 eShcbt7dl.Thsf ippWLdTAn 4 ifreEtl In wrnprtaOM w+lh San <br /> 4aagmn Caunly paysopment11tle Chapter 9-1ti5 3 and Int Standards a1 San Joaqu-Cau,ty Zriv"nneentat Heptdr Department <br /> ASSeseoe <br /> WELL Lotat"JPQ6-.lMwK4& LtIA& tmj.$4T"yAjkjeeff Pe.CIZy IL---2p PaRev <br /> PROPeRry Ownerultm 1.1Af_ �_AdCfC4t M� Cpl Ip L�D,i4neo<� 5��-pL'� <br /> G47 Cantrneo :k AcIdress gso W'!g4 9--400 <br /> r-onn.�ttant A 'aP` ,,t 1,301Prvo ef�-irr['L t� <br /> CIS CCtmbnoles r Tcwn%?i(y_ Ft'ng6 sedicirL- <br /> WGRICTO 3E pf"0011114190 <br /> 14or 1kELLlSORI4G EQt'ROBE wrORO U H HAN?�AUGER 0716iER•} DESTRUCTION(HooeytyaeNetow) <br /> qIL BORING A 13 OVER BORE. <br /> Q OE LL a_ _ PRESSURE GROUT <br /> °ij[r ,�..�-- Cros,t 5peureatrons <br /> COMMENTS 'y <br /> TYPE OF Y94" ,I&TA LLA112N TVP C c�i�SRi]CT QK Sh�ECIFiCAti(!►d$ <br /> !1 MOVFTpRIN6 Q 14OLL OW STcM DW OF @0r'S110LE's-'Z-"WATt61 E CASlro49� UL1{EVC-LA 4 N+nLL CAUSING rhw89ft - <br /> Q ExTRAcrON Q AIR HAMMEWDR VEN CASINO Tijrr NESS -GL-�v,.r__Q n_��c <br /> a VAPOR D Lnfp ROTARY DEPImol G4UU1 SEAL TRF_ ' TYPE TO BF L.SE'+ 0 ALk-jEA9 NOS <br /> a AR SPARCE!Ozore a PusR Powi GRpLJ7 SEAL PUurCp/*I a o (NOTE MAXIMUM FREE-FALL DEP 3'Ft is 30') <br /> pr <br /> XCILeORING a1-ANOAI.G�K G'�OUTSPECIFICATIOR �pr <br /> S �I'1l./t.�{ (,t� <br /> n OTHER n orwER ArPRCA 50;tI:4+aUCP 7i <br /> �.��p BaLTi:rJ TgAr`r=C 80x or (f 5 i dVc RPE <br /> COVOUCTOR CASING PROPOSEUT "- (II YES IRs tpn rfm,ons nem; <br /> COMMENTS <br /> NOTE OFFSITE BORMISS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 43 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> I hereby certify t1t I have preparl-dthes aFpttCattorrart&that&v work wilt be done in accordance with San Joaquin <br /> CaU My Ord1 a Rules nd R ULV.Qns,and all applicable California State Laws <br /> Synoz47 <br /> � TtIGICOrnp�rtr B'1 f(ti G <br /> P11111 Narro �tM-i ALF- tete Z3 a'} <br /> DEPARTMENT USE ONLY <br /> N <br /> I c.oP) <br /> SITE MAP IN UNIT FILE,ADDRESS <br /> WORK PLAN nATED -� <br /> APFIIQWI6nA WOL-daY DatalOStiAO ��3�� rea!i>•/� <br /> ;(&A Mrspee aA by QeIQ Plnaeuupeafon By ,Date <br /> DestrO=foll tnspeCt do sy Dale <br /> COMMENTS!CONDITIONS <br /> ACCOUNTING ONLY AID@ <br /> DECODES FEE114FO Attou,4r"i-re CmEc%s RECT)BY OAT@ pERDARt8ERY10EREGIJtS7a• tNvelCt: <br /> 00 3 i. <br /> C-57_ 10C�WAIVER C-57 Latter of Authortzatlon to sign per»ut_ Encrcechm nt dot:_ 8/29/O1 <br />