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10/06/2003 10:42 2093345374 <br />Dot 06 03 11:25a Wane woodward <br />10/86/2003 09:58 2093345374 <br />CJ <br />WGR SOUTHWEST NOCAL <br />1-707-374-5677 <br />WGR SOUTHWEST VOCAL <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 96202 <br />(209) 468-3449 <br />PAGE 03 <br />ORIGINAL <br />PAGE 02 <br />LOP & SITE <br />MITIGATION. <br />UNIT IV <br />Aitil <br />j�Qf j_REFUNDA6LF RMtT XPIREB 1 YEAR RR�III PATE M aL MD t I x <br />AMIC200n le herecY ff=@ tO Stn Joaquin Caunty for 7 Pwmlt m tonolnaCt and/or inatan the WOW dammbeo Thb apP Ica lon ib triode in a mplanro With sari <br />,laeaWn County oeuelopntant TRW Chapter 9-1.116.3 and the SmndafdS Of San Joequln County Ernlrontnentei He Nth Department <br />WELL t.ocetlon � �7� /�' /5 £ Cs• I Asee99ors <br />�SADiar09pR <br />PROPERTft�x�erP�r� e� �..rL _/td _W � y �p aPhone*12p1'446-Da Vs <br />C-67 COt1it'egor ddresa _,O • _QiQ —GIl) g1 1, �pg�{S�t I.Ic {BOO Fhone4f3� -43OC <br />ca,.ultattaIsubcna a�dre�_3i5, city.uol►s'�Ss_Pttana*/pg�3�-56 <br />N GIS CoofOM O": X 31a -Sb. R' Y-7,JL-a,,Vj:-. Tbw,"Ip Rangy Section <br />1 <br />MBK2013E PEREDRMER: <br />VEW WELL I BORING (CPT, CEOPRODE, HYDROPUNCH, HAND -AUGER. OTHERO) <br />a SOIL W"INo a DESTRUCTION (uwctse 01De below} <br />3NPl.L # ,_ 0 OVER -BORE. DIAMETER_ <br />PRESSURE <br />calui�rsrs: �—� <br />GROUT SPECIFICATIONST <br />IM OF NII6a,I, OTALt.AIM jyps ca �CIFIClITfGP,IS <br />X'MONITORINO )tMOLLOW STerm DlA- OF BOREHQLF .I l " 0 MULTIPLE CASINGS Q MULTI-LEVEL MLL CAGING DIA: <br />d WRAC7tON D AIR NALRAPAJORIVEN CASING TH10KNWS <br />� TYPE OF GOSING: p STEEL C <br />It VAPOR 11 L" ROTARY DEPTH of GROUT SFA, r �. v D t] n tER: � <br />G AIR SPARG&OZONE PUSW POINT fGP or CPT) GROUT SEAL PUMPEn `� TREMIE TYPI: TO t3£ USED; Q AUGERS D HOSE(PVC <br />p SOIL PORING U HAND AUGER Yea Tb (N07E: MAXIMUM FREEf/t I. DRPp,13 D') <br />GROUT SPECIFICq'TIpNS � � <br />d OThER ----,0 OTHPR APPROX. BORING DEPTH <br />oLTED TRAFFIC BOX or d sTovE ,PIPE <br />CONDUCTOR CASING PROPOSED (d YES, list apeclttcatlone "comme, tasdlan) <br />CbMN�IYT®: r-. <br />NOTE. OFFSITE B NQS REQUIRE AC ESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKINC3 HOURS NOTICE REQUIRLp FOR INSIDE Ms. <br />I hsr+by caMfy that I VAVa pTppared thiE application and that the work will be done In acCOrdaned with San Joi%quin <br />County Ordinances, Rui s and 0utatf dIlli applh:abls California State Laws. <br />Signee <br />Print Name 141, i <br />SITE MAP IN uNrr N FILE, <br />WORK PLAN DATED: <br />4PPrcattan AeerrptW By <br />Sroui Irm2Odkr By <br />2 1 -6 0 <br />9/30/02 <br />v► <br />Jf'' <br />