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' 05/03/2004 13 16 209468343q FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM TSITE <br /> SAN JOAQUIN COUNTY A41TIG 4TION <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHC) <br />' 304 E. Weber, Third Floor, Stockton, CA.,95202 UNIT I1/ <br /> (209) 458-3449 <br /> APpuullon es here!" NON-REFUNDABLE PI= 1T EJ(Pi 1 YEAR FROne DATE ISSuc-1 <br />' <br /> Joaquin Co y made to San Joaquin County fora Fw"M in r�nMCE andlor install the work dessnlbed This apPimmtron Is made in cam!chants:wetti San <br /> County Development Title Chapter 9-1115 3 and the Standards of San Joaqurr�CS5��unty Emu011 Meatal Healfi Department <br /> WeLLLocadon :3-7 1�AZELTc NA2t4�dn srl�L Assessors <br /> N Cross Strraet �_STuC,KTr,,,r ZaF °I <br /> PROPERTY 414RUL7� <br /> rpt <br /> I Owner wAdtlress •_1�!4Ze1�.rlryaG�£iJr17�p. Z9� hene# ��� 3-] x'7 <br /> C-S7 Conttactar Add (7 � ' WO !! <br /> Q Cdy- ZrpgJr` LtdF�l ophone#jk��i+.l <br />' Consultant/suta Cntr--Lf � � Addr�ass � f w i�� CdyyZPhane� ! Y B�/Qa b <br /> GIS Coordinator.X Y 7� <br /> Towr�slsip I3an9e _�,"Sedlon <br /> MgRK Ta BE F RFORMEb <br /> I ,J( lFfN'WELL!BORING (CPT GEOPROELF,HYDROFUNCH RAN01-AUGER,o'I�t� u DESTR UCTION (rhocse typ.waw) <br /> 8 SOIL BORIN(j 11 CVER-BORL QIAmETeA <br /> 3 PRESSURE GROUT <br /> COMMENM5 GROUT SPE+;IFfGATIOIvs <br /> I AM <br /> 'r"PE OF'NEL L UUSTALL-ATrON 3.'PE Sl?ECIFtf=ATIChM �-- <br /> a A40NITORING HOLLOW i Etut OLA.or-amr- ot.F,� it MIULTIPLEE CASINGS p MULTI-LEVEL WELL CASII lG DIA <br /> a EXTRA(w rICN p AIR HAMMHi41DRIVF:NcaslNO THICKNESS derv)t TYPE OF CASING <br /> Q STEEL�C U OTF ER <br /> ub F'CR U MUD NOTARY DEPTH OF GROUT SEA1, TREMIE TYPE;[D BE U � <br /> IR SPARCc!OZCNE a PUSH POINT{ta>}or C PT}Q,RCUT SEAL RJMPEp Ej LL DI S >I Hbslw <br /> OIL 80RING II HAND AUGER GROU1 SPECIFICATIONS B Y� rg�ln (ilIC3T� Til it -Tf� FRES-FAR3. Qf P7'Ff�S 3{?'} <br /> 4TH � 11 OTHER APPftaX BORING DEPTH, '! 841.rn 1i}7AFFIC SOX or 135 CVE PIPE; <br /> COMMENTS., CONCUCTOR CASING,PROPOSED_�y,�b --(f YES,4lst spe0jscahof3 In ca nment season} <br /> NO'S'E: OFFSITE BORINGS REQUIRE ACCESS AGREI=urtNT OR I~N s-oACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIOAIS. �- <br /> I hereby cerilllfy that 1 have prepared this application and that the work will be done In accordance with San.oaqutn <br /> County p s�ces ISI ntf Re • mons,arta a1I applicabie Cal f mi tate Lam. <br /> Signed x � <br /> T>Tle/Company �. , A <br /> Pnnt!Name CV <br /> Date ' t <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT;V FILE,ADDRESS: . <br /> WORK PIAN DATED:_ <br /> all <br /> Applrron Ac=WjW St <br /> y ^''� Date Issued SA/of <br /> t <br /> GArea_*4te <br /> I rant rrspet�[an Ely Date_- F1rIaI Inepe:c6on t3y Ch3te <br /> Desifuchon Inspee Con ay Date <br /> COMMENTS ICONprnams- <br /> ACCOUNTING ONLY- Alr* <br /> FAM <br /> PE CODES FEE IN; AMGI7NT t p CHISCK 0 RE;7C•D BY DATE PER1t I SeRwCE REQUEST At INVOICE <br /> C-57 WCC WArVER ,,.__ G-57 Letter of Authorization to sign permlt--Encroachment duc__ 9/30/04 <br /> I <br /> I 4 <br />