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03/27/2593 I8:57 20946P'433 FIFTH FLOOR PACE 02 <br /> WELL. PERMIT APPLICATION FORM WE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber,Third Floor, Stockton, CA.,95202 <br /> (209)468.344a <br /> N2*10FUND06LEAHNamem I ME MQM Mile ISSUED <br /> Ap06I;;im w bemby made to sm Jdwn Ga mty tion a Garth b ow&VM an ft,In41*11 IM work deser bed. 9f+14#pp4 sion Is made In compliance with 88a1 <br /> Joaquin Qw*Davatop, TW,Chspw 9.114 3 and the owda+de or San JmquM CounlyEnvkwwankd Hearth Dspertrnerd. <br /> WELL L M SaxCrou awes sty V--P- zls� os PAna n' zy <br /> PfIIQPlEi61'1f Ownerr� ra< ax C3.t yy Cltysz' �.�._s zt,oMt__p <br /> car contrNe�or <br /> __Add � •J!r `1/F cup 1a � r z,pg4�Y�Ll �'�11plyo c & ZZ y/*'o <br /> Caneu(tentrt9ubt�ir�r�o i� d city��{�ua�[� '�1t3 Phor� �'S��.z93 <br /> COOIdIMIIs:X� Y _ ,Towneh� Renga Seeison <br /> =1a of Flamilm <br /> EW WEILL I SORINf3 (cpr CI3 t.myoRol�urucH,HANo AuGFFL+oTwR') 0 DESTRUCTION {dxow type hetero) <br /> 0 SOIL K ttt4G d •,fy f�3 0 OVER43ORE. DIAMEM <br /> 9 WELLS 0 PRENURE GROUT <br /> 0.00 r14ROUTSPECIFICATIONS <br /> COMMENTS: f Orlwst las a^iJ 2 40'rl` 47 Y 717 '90 <br /> MzL2zAU INBTALLATION TYPE <br /> 0 MONITORING a HOLLOW STEM Dt0L OF BOREMOLS&E_ a MULTIPLE CASINGS g MULTILEVEL WELL CASINO DIA: <br /> a EXTRACTION am NA#rrdERJDRIVEm CASING THICKNESS­&A_TYPB OF CASING: 0 STEEL C PVC O OTHER <br /> 0 VAPOR 0 MUD ROTARY DWr-I OF GETOUT Sl1kLiD 7b Td TREMIE TYPE TO BE UNIX 0 AUGERS 0 WOSE <br /> b AIR SPAROW OZDNE pKPLISH POINT(GP or CPT)GROUT SEAT.PUMPED: a Yes U No (iiM:MAXIMUM FREE-FALL DEPTH IS 301 <br /> $dL BORING Q KANO AUGER GROUT SPE CATIONS- G/Ar J - M^Z: _ --- <br /> Q OTHER:--- n o-NCR A"nox,DOMNG DEPTM 0 aOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSER, AIA Of YEe,Ildt epndflG@ rw In ram ont aecdon) <br /> ooIISeMI m <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> U WORICING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I heroby etertidy that 1 hafN*Pr*Parod this application and that the work will be dor*in&w4rdarwA with San Joaquin <br /> County Ordirentpe,Riules and Regulations, an applicable Callfornla State Laws. <br /> signed 'ee Ttdelrrompt�yr <br /> fd,t mwm S 4 4 v,,e Data a <br /> DEPARTMFo USE ONLY <br /> SITE MAP IN UNIT N FILE ADDRESS: <br /> WORK PLAN DATEfi <br /> D::� _ <br /> ApplicakaAccododsyr°�i�`g-" Dolefan+ec -- _.^.�_14w <br /> Grout haPeOm By a Pini Inapeodon By Dela <br /> De K001Date <br /> COMMKINTa/COItOr MIS: d j MA,ARCOUIMMIG ONLY: ADS PAC* <br /> P9 P,M" AMOUNT RE ITTEA CHECK• ItIIC D aY I DATL PORW r OMME RECUENT O NVOICE <br /> of 8' 8f" 37LI 1 ,kms- o SR#oo ol, <br /> G57 WG-WAITER-_ C-57 Latter of Authorim ion to sign Wtrit,,.,-,-EncroachMent d0C 9/30/02 <br />