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Mar-20-02 12:39P VIRONK, INC_ 510 �$ 7679 P_06 <br /> 03/20/2002 13:04 2094683433 FIFTH FLOUR PAGE 06 <br /> 03/05!2022 09:35 :e0y4bt J4J-J rlr in rLwrc r."._. <br /> ;if:AL 1 E WELL PERMIT APPLICATION FORM SITE <br /> �- MITIGATION <br /> n x ty� SAN JOAQUIN COUNTY UNIT IV <br /> OL <br /> ft'1 20 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber,Third Floor, Stockton, CA., 95202 <br /> (209)468-3449 <br /> dptw.REfUNDiABt.E p RMrT E 1 FROM jE tssuea <br /> ppt%at an is hereby made toSan Uoegs'in County for a pumit to oone4ua.an4tcr[ratan M vA5*described. This appllCplian b made in compuAca wish San <br /> nagWn CoUnty DO—IopmerA TRIG,Unaptw f1.1113.3 and the Siandwd!$of$an Joaquin(;,Wty En�ko"wm tl Health napartmentAssessoes <br /> cN. 'lt <br /> 61ya ' VOWI eek teem <br /> WeLL iocabon US F'. ''� R'I"'�� -Cross Sbeet CItY gyp— ••••• <br /> ROPERTYOwn�r (n G. Acla+2ss c :a c Cih���xrLwNd Z,p�I�24'J Photw}f 7-09 9-8'+6L <br /> :.57 contrecmr'y t�'Gl'LP�SC Address `�tl O A�awrv� •' � cityri?iPQ+fS�7 I,,ex7 "►Phaneft Sf b-Stirs <br /> ^ L7I. <br /> :onsultxmtfSubGarrtroaar i-" LOA-(' nsSdroea �IU05 PwfC},ic 4y yi�anCt'tzD Lidkl'3t'E2� Ptj0r4W <br /> its Coarplrtaees:7[ Y TownshlP V? Ran" - <br /> 1IORK�fERFOsiNEo_ DF.S"fRilCT40N lChooSA type LrJow) <br /> ]NEW WELL 1 BORING(CPT,I EOPR08E,HYD OPU CH`s,", N 6 UGER,OYNER7 C] 13 QTR$ E <br /> iL t30f�ING 7F„ a pPtKSSMRE GROUT <br /> �1VE LB Mw` <br /> att+ar: A 150 2 - c ec*A spedaeatiflna <br /> :OMIti ems: -2 t <br /> rvrE OFtort Ipd.§XMt..sdroat Tvpf e4kS1�t pmy SPECWICA^TMS ° <br /> pNITORWG OLLOW STEM DIA,OF DOREHOI-Ti� l!MULTIPLE'CA91NW?i1 YES WELL CASING qIA 2 <br /> ]gxnvCn0N Q AIR HAAWURIDRNIEN C kSING THICKNESS 0 D T TYPE qt cwsiNG: Q St st *V A pS6 <br /> ]VAPOR Q MUD ROTARY DEPTH OF GROUT SeAL a�—TRFMie TyFF-Tv 6E UsSQ: •d AUE , <br /> ]AIR SPARGE (I PUSH POINT GROUT SEAL PUMPED: pYca )*No (NOTE:MAXiMUM FItEE-FALt-DrMPT A IS307 <br /> ]501t_t�ORING Q HAND AUGER <br /> GROUT SPSGr-trr,7ION5• XTPD TRAFFIC SM, nr o STOVE PIPE <br /> ] <br /> OTHER:—U <br /> O1M&R APPROX.BORING DSP t M �S 1 <br /> CONDUI=64 CASING PROPOS=r1? (Tf TE5•Iia spedfizaltons herd: <br /> 7 � <br /> 'LOlHMEIITs' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR EKrp.OACHMENT PERMITS, <br /> -CALL THE UNIT IV INSPECTOR 45 WORKING HOURS IN ADVAWCE FOR ALL REoUIRCO INSPECTIQHS- <br /> I heroby csrtifj That I have prepared this Application and that the work will be done in accordance with San Joaquin <br /> County ordinance-, Rules and Regulations,and aN appiicable canfornin State Laws. <br /> std+sax _ Trda�CemoanyU1.2 L <br /> 12. S� <br /> P'"t"art14 DEPARTMENT SE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> _ Bala�6 I <br /> APpfieaUwt Accepted By,,,,,�.�k&1 � [Sete <br /> Grout Insp cdc"BY daftE _ orad Inspection By <br /> Dnstructisn InSpeetinn ey !lite <br /> commeNTS f COWOfTI[OKS <br /> /kCCOUNr1NG ONLY: AIDS ¢p,►lr <br /> PE�QDES FEE taFO AYt9t7idT fiEM177ED cwEC a RECD BY DATE P�tMiIT!sEAVICE RECUES." NVCIP>G <br /> ( <br /> G-57 W -WAIVER C-57 Le"er ' f Authorization to sign perMit_EMeroa*=hmarrt day.--- 1/ZS/02 <br /> 03/05/02 TUE 09;39 (TX/RX No 54041 Q003 <br />