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Apr 06 07 02:44p Lautenbach <br />Apr 6. 2001 1:20A <br />Wright Environmenlal 832-5152 <br />1.408.371.4583 p.1 <br />WELL PERMIT APPLICATION FORM <br />�� 0 cG`. SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />p t=_Weber, Third Floor, Stockton, CA., 95202 <br />(209) 466.3449 <br />No, 88 ORIGINAi. <br />SITE <br />MITIGATION <br />UNIT IV <br />ILON44EFurs2A&E PST EXPIRES 1 ja&W FROM DATE L2"M <br />Appllcatlon is hereby made to San Joaquin County for a permit to construct and/or Inatell the work described. Thio epplicatlon Is made In compllanoe with San <br />Joaquin County Development Title, Chapter 8-1115.3 and tate Standards d San Joaquin Counly Envunnrnentel Health Oepartment. <br />Assawvs <br />WUL Location 3 `lS' E, / 1 11 5-r , ____craw streot/0 ,4 PTHyIZ _o(y T/�A�Y zip `l3 376 cew <br />PROPERTY C-0)( t CO>e P - <br />Owner U� J7ENllt-��p _Addaso'.86+Z 14.-rV6LUrr,uE city-jwAuA; -' <br />AAAzio9S383 Pn� le <br />one"?- 586 -T388 <br />C4Y Contractor <br />Consume rd / Sub <br />Medd �N5 Y3,E, P-SCADEROc iK �/ LlcJf 6515D —Poo" �`�-6 a3-t�7�A <br />GIB Coordnates: k 1 = I '.-124 Townehip Range SmIlon <br />!IRK TO V P_g$?g eD; <br />,(NEW WELL / BORING (CPT, GEOPROBE, HYDRO PUNCH, HAND -AUGER, OTHEW) Q DESTRUCTION (cnoeee type barow) <br />0 SOIL BORING # a OVER -BORE. DIAMETER <br />jNELL <br />'Other Av64 �nl�y Poi- PRoGE c OPIRUTS ECIFICATIONSccTS: <br />TYPE OF WELLINSTALEAT _� CON8IRLCTIOH $PFSIFICATIONB APER W9-ki, PI -A"/ Acca E11DA1'pil+kvEi� C'o1�D, <br />u MONITORING Q HOLLOW STEM DIA. OF BOREHOLF.7= V 0 MULTIPLE CASINOS 0 MULTI-LEVEL WELL CASING DIA: t <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [?STEEL I]PVC jj�bT1-1ER= /r j"-dN <br />VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)OROUT SEAL PUMPED: 0 Yes C No (N : MA)OMUP4 FREE -FALL DEPTH IS 30') _ <br />0 SOIL BORING )<HANDAUGER GROLITSPECIFICAMNS_ 72> <br />U OTHER: p OTHER APPROX. BORING DEPTHD� BOLTED Tt2AFFiC BOX or 0 STOVE PIPE <br />mment 22Z&nj <br />48 WORKING 14OURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby cer ft that 1 have prepared this application and that the work will be done In accordance with San Joaquin <br />County Ordinances, Rul Reolatione, and all applicable CatliforniaStnte Laws. / <br />Signed x �? C t / 1111e/Cornpany G%U!/�. L</!yI ��/� ! ` T �/1W/ ` <br />Print Nerne�(� /Cp • �1 GI 7�N8L� ({ C E / a? Y 37 Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FII P, ADDRESS: 545 (( '] LOP- <br />WORK PLAN DATED: I 1 -1 <br />Application Accepted 8y _Dale traced_ JW G - Area CL "N <br />Grout hw4jectlon By �d to fine 1-5PM.0011 By . ,L_ _, Dam— 6- -0- <br />CO9AMIENTR ! CONDiT1ON8: <br />ACCOUNTING ONLY: I AID# <br />PE CODES I FEE INFO I AMOUNT REMITTED CHECK # RECD BY I DATE PERMIT SERV! REOlfEBT N INVOICE <br />36c?,-,& ? .— IoZT +1() SR# 6050Z1 <br />C-57 WC -WAIVED_C-57 Letter of Authorization to sign permit ncroac ime.tt doc N 9/30/02 <br />XD/ <br />- sJ� �3.�. �. <br />CirS' <br />