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3 2354Jayt33 FIFTH FLOQO =AIGE EI <br /> WELL PERMIT APPLICATION FORK! SITE <br /> DEC 10 2004 SAN JOAQUIN COUNTY MITIGATION <br /> �I�rfr��ov',ic,VT,'LAL h ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> Fc �'``I�;3- C1 S 304 E. Weber, Third Floor, Stockton, CA , 95202 <br /> (209) 468-3449 <br /> NON-REF=UNDABLE PFRMI7 ExP413ES 1 YEAR FROM DATE ISSUED <br /> Appl,citcr s hs ebv made'o San Jcaginn Ccun'y for a permit tc consauc andlor install the uvodt described Thi eppl c_tcr 4 trace n=-rpl;ance watt San <br /> Jcacuin County Development Tile CFapter 3-1113 3 and the Stander(�S of San Joagrin County EnWrOnmental Health Department. <br /> h1 DU Lecatlon 2-12.. �no�+k S��y � Or Cross Street 5Pul- I-A. City ��OG� Cr) ZiO S2dfe p�e#6f 1 J7 —6/4? <br /> PRGPERTYOwner H H C n�] S` .ntt-lam Andress.. 9? nal. ,s�r�al e city S z zp 4Szg(o pr►wnE# �3--0705- <br /> C-57Contractor �rsGr t Gt1-t. addra:s 34vi 1tiF,r tot(.v City r)ul�ILYser.r49 Trp 4 Gc. Et?SPhfln� ?w- <br /> Canr-U1t2nt1SubCantraa4ar G10,10\ ?-V-0 A-1011 =Addrsss 71Li McAIn b}' City �se�r�D 1 Les;RG�G cne�► g i� <br /> GIS Coord rates X Y Section <br /> MEK TO BE_PEPFORMED <br /> S NEVV +VEL L 16CRIN(5;GPT GE]PRO$E MYOFOPUNCH,HAND-AUGER,OTHER) 0 DESTRUCTICN,anocsetyoa below? <br /> I SOIL BORING# 7 0 OVER43ORE <br /> a WELL# u PRESSURE GROU` <br /> `Other Orcut 8pacmcatona <br /> COMMENTSLl cr, s 5'0` IIS 40' 1 P l0' <br /> TYPE OF WIRLr IN9TALL4TION_TYPE CONSTRUCTION SPECIFICATION,B <br /> a MONITORING D HOLLOW STEM Gla OF BOREHOLE MULTIPLE CASINOS'0 YES 0 NO WELL CRS'NG DIA <br /> o EXTRACTION aAIP HAMh1ERvDRIVEN CASING THICKNESS TYPE OF GASING O STEEL p PVC p 07-fER <br /> a VC PCR a MUD ROTARY QEP-r-OF GROUT--SAL 0e0b TPEM1E TY-E TO BE US Er- 0 ALGE-S i HOSE <br /> Q AIR SPAPGE I BUSH POINT GROUT SEAL PUMPED n Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 1 SOIL BORING U HAND AUGER GROUT SPECIF CATIONS <br /> OTHER. -- j]O i HER__ _ APPRDX I3Ci�{NG D=PTH ce GO++n ©HOLTER�TR,4FF C BOK or []STOVE?IPE <br /> CONDUCTOR CA31VG RRCPOSEDe t�fYfrS 1s sp�Gifar:-bons h44) <br /> COMMENTS <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> I hereby certify that I have prepagerl this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances, Rules ancr ulat4onis, d all applicable California State Laws <br /> Srgnedx, `-"r—� / +~ TtlefCornpanl !� G i:�V="p �t<'�s+a r✓�*i'le t <br /> Print Name ZL G c-A�' ?- ��++--�¢/- Z- - -Date / D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS' :2 12 T_ n ) a I T r)24` <br /> WORK PLAN DATED' 5e + � -2 I <br /> ApplicaJon Accaptetl ay i '7 eaue Issues_ 1.2 z o� D 4 Oran <br /> Grout trspcctCn By Dale Final Inspe-cGon By ! Gate <br /> Destruction Irmpecbon By Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AlD# Qt, <br /> PE CORES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUE8�# INVOICE <br /> 3501 69,00 P"99 40 1 1 sgg ao4Q725- <br /> C-57_ WCT WalVE C-5r Letter of Authorization to Sign permit—Encroachment des 1/25/02 <br />