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r t. WELL PERMIT APPL1CATl" FORM SITE <br /> MITIGATION <br /> (i SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) <br /> 304 E.Weber,Third Floor, Stockton, CA., <br /> 95202 <br /> (209) 468-3449 <br /> NN SUED r witn San <br /> I! NON-REF DABLE PER FIRES YEAR FROM DA <br /> 'Applicadod is hereby made to San Jcaquin.�CounH for a Permit to conswd andlor;nstad the work descn'Eed.This a Health <br /> Deidn b made in mmPOaq� <br /> Assessoes <br /> Joaquin County D'slopinentTide,Chapter&1115.3 an fha 5tsndards of 5a qu1^County E rfarO�iP Depadmen� t Yi-- <br /> 1 Jho /C[) crozsstraet S(fL aH A 9Sg-5v33 <br /> WELL Lora6an <br /> GtY Lk rrh z �p 19 31f1 Pnonea___._-- <br /> toss <br /> ,PROPERTY Owner [1- rr fe,N �j ft��p� ajUsC� Phonex�p.----� <br /> S, .l({'U✓LC G b r Address r- s 11d UG'F�hone0 (. <br /> ( C�/Contracmr ,� 1a�t/ Address a'�}f�—Ty C Ctty YO . <br /> tl Kle,I/ 't Secaart- - <br /> fGta <br /> nsuttantf ub Contractor Renge�-- <br /> Y_�—Township, <br /> Coordinates:X� [j DESTRUCTION(ctloose type be,") <br /> I II OVERBORE <br /> WOR TOBEP RFORMEO: HANp•AUGER.OTNER') dPRESSURE GROUT <br /> EW WELLY BOWNG(CPTG SOIL BORING �OPUNCH, _ ' <br /> �' i <br /> �CyfELL# IWe Grout Specifications: <br /> q <br /> COMMENTS: - r <br /> INSTAL t 4TION TYPE CONSTRUCTION SPEc1rlCN t0 <br /> TYPE S ' GO-OF BOREHOLE MULTIPLE CASINGS?13 YESxI S. PVC WELL OTHr DIA:� <br /> PL <br /> MONITORING HOLLOW STEM �y <br /> pEXTRACnON- .O AIRTtAMI.IERiDR1VEN CASING THICIWESS �� 20 TYPE OTgEMIENTYPETOTBE 6ED: D AGEFtSR HOSE <br /> p MUD ROTARY DEPTH OF GROUT SEAL 9-P r <br /> p VAPOR PUSH POINT GROUT SEAL PUMPED: Yas 0 No (NOTE. <br /> M C>ti1Ut EE-FALL DEPTH IS 30 <br /> Q AIR SPARGE O ANGER GROUT SPECIFICATIONS: r d BOLTED TRAFFIC BOX crXSTOVE PIPE <br /> U SOIL BORING - 0 hIAbI APPROX.BORING OEPTH ' <br /> j1 n GTHER� CONDUCTOR CASING PROPOSED? (it YES,list sped6cadons hereX`� <br /> 'i Q OTHER: <br /> 'COMMENTS' i� ' <br /> NOTE: OFFSI tE BORINGS REQUIRE ACENCROACHINSPECTIONS. <br /> MENT PERMI <br /> CESS ORTS. <br /> L REQUIRED <br /> CALL 111 UWT IV 1 SPECTOR 48 WORKING HOURS IN ADVANCEFORAI- an Joaquin <br /> at 1 have prepared this application and that work will be done In accordance with / <br /> 1 hereby cartlfyth ulations,and all applicable California S s tai <br /> County Ordina es, Rules a�r� 9 Tlde/campamr 7.f.. <br /> �I 3 J <br /> Signed z -- ESC k/l/ <br /> PrintName '��ru- .5 <br /> DEPARTMENT USE ONL , <br /> SITE MAP IN UNITi D RAE@ .a <br /> WORK PLAN DATED: —4-1k d A w <br /> I - Date Issued <br /> 11 ,.�tM Date�.— <br /> t. Appiicadan Axaptad BY r ` ' Date Final Inspection BY <br /> Grout lnspec4on BY �I Data: ' <br /> .. Deswo6on Ipspecdon BY <br /> COMMENTS f CONDInON5: <br /> INVOICE <br /> ' <br /> ACCOUNTING ONLY: AID#� 0UNT RECD BY DATE PERMn'IS <br /> �E REOUESTit <br /> pE CODES FEE INFO pl5IREMTRED C` Q SPA S _ <br /> dock._ <br /> G57 Letter of Authorization to sign permit._-._Encroad+menT <br /> ! �� 03/26/2004 FRI 16:46 [TB/RX NO 92601 [ 002 <br />