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Mar -20-02 02:48P VIRr '�_X, INC. 51(` 68 7679 P.05 <br />03/20/2002 13:04 20946L 3 I- it- IN rLUur< rHac. rij <br />03/051'2002 139:36 2094683433 <br />FIFTH FLOUK <br />WELL PERMIT APPLICATION FORM ITTEIGATION <br />SAN JOAQUIN COUNTY UNIT IV <br />ENVIRONMENTAL HEALTH DEPARTMENT45 02, <br />t 344 E. Weber, Third F100r, StOcktar7, G <br />(209} 4+69-3449 <br />IT XP 7 FROM OA O <br />N -R TNs applial w is made in rompNence wish San <br />^�- t m oonslruct andlor Inalen the work de- <br />ppNc�h is rIcFet3y mods is Ban JDaquin County 10► a Dt►►rH EnrirOM"n"' Maelth oep-tr—r%LA �sor 7 <br />,gquir Wurty Ocvetnpmeni Title, Chww 9.11 15,3 and the Starawds of San Joaquin county tI G <br />OYI 91'k - (, 2-7 Do -v ('VIE. Cross Sbsek <br />tELLL"StI11on10220 ��vu. Eifct"Ilwg �{ G),y��xr a►tO .Zp *22'J Phone#_%29' +-1 ^�`�bi, <br />ROPERT'✓a"ngr Gl�v�-+ �nG Adaress-Le 70 <br />P <br />uoxIC'5ba-767 <br />Pnot,elttl 5 <br />51 CentrgCtor vac- Addrwn <br />o r p .w�ss H Ua5 t o� Ch�ca • v !q, �o � >�dl f3�� p►,o►+�It X125 2�s�1 <br />:onsultant / Sub ComW24t1Or C Secgon <br />. Y J Township Rangv <br />;IS Goofdln3les: X_„��-- <br />ueR1C *r 9E P�RFOiRMEO: 0 DESTRUCTION (choose tYPe W—)NEW WELL t BORING (GPT, CiEOPRDEE, HYDROPUNCN, HAND -AUGER, OTHER.) OVER$ORE <br />SOIL BORING 0 PR6SSUftE GROUT <br />WELL S„ Mytt- '} Cmut SpedOcmtk— <br />Othe' <br />_pMMENTS: <br />ryPA MLL <br />INST LA —PE <br />MONITORING <br />jHOLLOW STEM <br />I EXTRACTION <br />D AIR HAMMEWMIVEN <br />]'VAPOR <br />p MUD ROTARY <br />] AIR SPARGE <br />i] PUSH POINT <br />17SQIL BORING <br />O HAND AUGER <br />1 OTHER: <br />,n OT"'GR_ <br />_ _ g-.-."..wtu+u �e�FC61C�71bNS <br />NO WELL CASING DIA' <br />DIA_ OF BOREHOLE_- MULTIPLE CASINGS. Qy D <br />CASir40 THICKNESS —0,07- TYPE OF CASING: 0 STEEL ,4PVC (I OTHER. <br />DEPTH OF GROUT SEAL 7 ` _ TREMIE TrPE TO BE USED: .D AUGERS OSE <br />TH IS 301 <br />GROUT SEAL PUMPED: DY— eo (NOTE. MAXIM FRftsE-F �� <br />MouT sPECIFICAMM <br />r � pTFIC ROx - D sTOVE PIPE <br />APPROX. OVRING DEPTH_ fiy__ <br />CONOLIGTpk CASING PROPOSED? (if TF3, est spectfIC@dW3 here)._ <br />'COMMENTS: � � t <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT iV INSPECTOR 4s woRKING HOURS IN ADVANCE FQR ALt• RECUIRED INSPECTIONS_ <br />I hereby csrtify that I have preparwd this application and that the work will be done in accordance with San Joaquin <br />County Ordinarba , Ruins and R®gulations, and all applicable Calffturtia ate` Li r �� <br />TnldGo►npsny Jl <br />signnd x <br />Pam <br />Print r;ane _ (.as.aeTRu12-111611Ti1 %1: DNLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: �I C-'Ly'`" �)" ` � <br />WORK PLAN DATED; ( U"p l)L <br />Dabs Issved.�.1�_. <br />gppliCntlon Acttpted ft r' Fate) =J64InspeBY Da(E_�— <br />GrnutlnsPco6oh RY_ <br />f \ L Gate t C, <br />Dastructiar• lnapCction B <br />Data <br />coIMIMENTs I GONDTTKWS' <br />ACCOUNTING ONLY. AID# PECODES FEE MUFO gMOUNT REMITTED t=NEGt]j <br />EC'A BY pATL► PERmrr I�,c,QUEST t INVOICE6 �1� zr e <br />C-57_ WCC WAIVER._ C-57 Latter of Authorization to sign Prr'mit_ roach_+ oc`__ <br />va5ioz <br />03/05/02 TUE 09:39 (T3/R% NO 54041 Z D03 <br />