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12/07/2005 14:24 20946834?- EHD PAGE 01 <br /> *4000' <br /> nin County r1V <br /> San Joaq <br /> LR SITE <br /> Emaromuenral Health Depallnu <br /> 3.04 East'Wcber A'venm,3rd V100r,StOdOOn-CA 9 " 1 7 2005 MITIGATION <br /> :NFV <br /> (20V)468-i449468-i449 Fax_(209)468-3433 N Ve b* UNIT TV <br /> ........... ENVIRONMENT HEALTH <br /> <.- Well Permitt,Application: PERMIT/SERVICES <br /> K0N_RZFuN0ABLF_PERMIT EXFRRES I YEAR FROM DATE ISSUED <br /> Applicatimis.nerebvIrrime to sm Jcamii.n cpuntyjor nj pem-t tD=woct andr iratatj the vmirk ThizapOicaisr.is mad-_in com;Aancelmm San <br /> josqtgn!courpl De element Tihe:.Cha�r s.y1'15.3 and.the Smndarm of 50m Joaquin C=ty EmirmnwnO Health Dew-ent <br /> Assesmm 163-31M7 <br /> WELL Locstion W50,Naw Drive_Cm%Stree,-_�Zie Lew�lscjty <br /> PROPERTY e'al LLC <br /> cwawr. Co 209 N;ay.,/Drive rjW StOCK'On zm 45206Phorag_ <br /> C-57 Ccr&8.VW_!rNIC101_%—Sarr2li-EL9 _Addl-09_10D1 ES90 AY&nu.e ._city '57E <br /> — Richmond ;J;�C.44801 Uc;�.�397P anak(510)BI-4 <br /> AR�_ADB 1 Y'G Marina may South OW Pharr I'0,Hai 233-32UC <br /> constitant I Sub Mnv Adamw I�Ich.=Fld <br /> C,M C:Omsvates,X 647781.4 y 420 K19-J,.8 Tcamttp_R�'�__Secbm— <br /> WORK TO BE PERFORKED- <br /> )YN,FzW WELL s SORING r,cnv,c.,somaisa myDRopuw3l,mAXD_AL8G-r_-R,0-mew) JIDESTPUCT1014 (rhoctsetypo be-jowi <br /> )r-.OIL BORING 0! SBI a MIER-®ORE_ DMETER— <br /> PR:-_SqJ.RE GROUT <br /> COMM-E—NTS: <br /> MEL0_Vr-L L qNSTALLMiN TYP'E CON'STRUCTIgN SPE0FV(ZA71QNS. <br /> 0 mowomc' D HOLLOW S-r=m DIA.OF SOp_=HC)Lg_2" 1]MULTIPLE CASINGS 11 WJ1_T1-L0!F_L WELL 4,-6.SJNCZ 01A- <br /> [taxTnACTIOM AjP�,WAM%1EMRF%-=N- CASING TI*ff_-KWffSS_'-!YpE 01 CASING, USTEEL 9:PVc VOTHF-rt <br /> 0:VAPOR WDE RDTAKY DEOTHOFGR!IUT'SEAL-3()ft_Ts'EMETYPE,TOBEUS.-=: E.AUGERS 0 HOSE <br /> I3 AJR SPAIRGEf OZONE PUSH PONT JGP or CPrGRCR.Fr SEAL PUPAPED: Yes XIG (NOTE:MAXIMUM FREE-FALL DEPTH tS 30') <br /> ,ff'SaL SOMISIG D RAQ-0 AUGER GROLF SPECIFICAT <br /> OTHEFt_U PPROX SOMG DE?7� 3nOLTEDTRAMCBOY or USTOVEPIPE <br /> CONDUCTOR CASING PROPOSED_n* (if yES,list specftvtj�ms in ccnumentoecficq4 <br /> NOTE: OFFSITE SORINGS RE-WIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certifyr that I have prepared this appticaWn a nd-that the work vvill be done.in accordaince with San Joaquin <br /> Connty Ordinance l,Rules and Re u1sGo ,and ad applicable Calftmia State Low.&. <br /> Skan:xi x— Ct� '� 'Mm .-rftjCQ=5ny8;q-0 GeDbg1st I ARC-dYS <br /> onm Name C45.e lb odwd Datc- November 16-2005 <br /> DEPARTMENT USE.ONLY <br /> SITE MAP IN UNIT N FILE,AD-ORESS: <br /> WORK PLAN DATED: <br /> ApoUcaf.m Ac=pW Fq_9- --e Issued AM <br /> C-4w9 Impec5m Finall ImWctkn By 10=_ <br /> Da=L,&Jcn incpec-bop%r Date <br /> COMMEM-51 CONDMm" <br /> ACC=Zi ING ONLY: AIO# FA-_4 <br /> 7[ <br /> PE CODES FEE INFO ArAoUtITI pi3orrrED CHECK-.r REM ErY DATE PERWT SERMVICE REQUE;ST V MaCE <br /> 0-1 6YI,IN 1116(40 _LK) 7Y. <br /> I <br /> C-57_ WCAA_TVER_ C-57 Leit.er of Autharizofton to sign permit Encroachment dm_ <br /> ao 2%.W. <br /> 6,22V& <br />