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�J 4 <br /> 04/01/2004 11: 30 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APP! cAnON FORM <br />� SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV. <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95282 <br /> (209)468-3449 <br /> NON-REFLINU&SE PERMIT EXPIRES 1 YEAS FROM DATE ISSUED <br /> Application is hereby made W San Joaquin County for a permit to construct and/or instal the work described. This application Is made in compliance with San <br /> JaaWle County Development Tlea,Chapter 81115.3 and On Standards of San Joaquin County Envimnnamai Health Department, . <br /> 1 i rev'd a� cic t q,l'2.a i Aseesaat'a <br /> WEiL Location 8 r bO T Cross StreelL. a Cttyr �Zip_ Parretti <br /> PROPERTY Owner Det 1. Desk&Y __Rddrits.Z� Par _ri oily e- sate zip.10147-Ph #on92/Z2c S -t j <br /> C'.57 contractor I&(-?- eh44,er-mo-4ddre:se"00 1��'a4t S Clty,�Gr /�w�p ,i�1 z>'dhonaA Sp 3.6_�Yea <br /> Consultant ISub ConfraaloA-4, 'jf�luz,r A Address Uy <br /> . <br /> GIS Coordinates:x Y Township Renge Seetion <br /> i <br />'k <br /> WORS To BE PERFORMED: <br /> EW-WELLI BORING(CPT.GEOPROSE.HYDR CH,!1AND,AUGER.OTHER-) 11 DESTRUCTION(chovsetypa lslew► <br /> *SOIL BOR10# r 1z 0OVER$ORE <br /> g-WELL#_ I / d PRESSI! 5 I OUT <br /> 'Other: �.. Grout c1.*1 <br /> COMMENTS; <br /> , <br /> jrPE-OF INSTALLATION TYPE CONSTRUCTIONS ON � <br /> MONMORING OLLOW STEM DOF ROREHOLE <br /> .� IA. ULTIPLE CASINGS?a YES PO WELL CASING OIA:-Z-Z-h,-A ! <br /> p EXTRACTION AIR HAMMERIDRtVFN CASING TRIC NESS %PE OF CASING: 13STEEL XPVG p OTHER: <br /> Q VAPQR Q MUO ROTARY DEPTH OF GROUT SEaI-Zfa� tole 1YPE 1 O BE ERS )gIiOSE <br /> p,uRSPARGE 11 PUSH POINT GROUT BEAL PUMPEp; 11 Yea "o (NOTE: MAXI UM REE•FAL DEPTH IS 3D') <br /> u SOIL BORING Il HAND AUGER eROUT SPECIFICATIONS: -"r a r•rA e ♦t -j •ra'�s 4 <br /> p OTHER: ID OTHER APPROX.BORING PSPTFI 3S --eV$OLTES TRAFFIC BOX yr 0 STOVE PIPE <br /> CONDUCTOR CASING PROP SEDT (if YES,list spedntaderes haft)' <br /> 'COMMENTS: U i�l : b r J+ Q Mz rz 4 r <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 43 WORKING HOURSIADVANCE FOR ALL REQUIRED INSPECTIONS, <br /> I hereby-certify that f have prepared this application and that the work will be done In accordance with San Jcmquln w <br /> County Ordi ances, Rules and Regulaltions,and all applicable California State Laws, <br /> Signed x- ;,-,z .�- ` _. TilialCOMpany !d l0 3'f tP r <br /> jj <br /> Piint Name S N C k • ` r ra�o� Rale Y L <br /> 2EPARTMENT USE CMIL <br /> SITE MAP IN UNIT IV FILE,ADDRESS; <br /> WORK PLAN DATED". <br /> Appfcat{on Attapted By els Issued r� <br /> Grow!Inspection 6y �D�le al Inspection By Oate1! <br /> Destrudon Inspection By Dale <br /> GOMMENT5lGCNDiTlONS: Nb L <br /> I <br /> ACCOUNTING ONLY: AIS0— <br /> PE CODES FEEFKFO AMOUNTREMITTED CHECK# RAC,91in DATP PERMIT ISERVICE REQUEST# INVOICE <br /> 3S . DC7 T MA,9 1 V?�k 5 <br /> C-57__ wc�_WATVER C-57 Letter of Autho ' n sk4n permif_Encroachment doc`. 1/25/02 <br /> a 'd 9968-668-SDB 'OuI `40F-+Ply '8 R91eH Wdia :i? i'D'OZ TD odd <br />