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rj r1 141 ZIDLId 1b I U } 2694683433 FIFTH FLOOR RAGS 62 <br /> 07/14/2003 14.01 9158610430 SES <br /> f Rpp IoPa B <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY M11IGATION l - O <br /> ENV140NMENTAL HEALTH DEPARTMENT(END) UNIT IV <br /> SIM E. wober,Third Fluor, Stockton, CA., 95202 <br /> (209)48$-3449 <br /> o U-1im rr DIPIRES I XE68 Iffiam 9= Lieu <br /> Apph=tjan is haezy made to San Joe4uin Cou*tar a Permft to c x,sWc ar Grinsm no wow de"'bed Thre o icaft Is mode 4n oomp snee with San <br /> Jna"Cotinty ombpment Trie,.Cha0m 9.i 175 3 and the Wnderd8 of Son Jotiqurn County Environ erntal Health 0 PdrtrWf <br /> W7=LLLPCattonZ., 4 - LOun�r GtU6 8xyil ��auvet 4a Gkr Sj�y-"e% � �t5x F vrW# <br /> r <br /> IoPaF17'Y <br /> O ��eve+n G, dress 0" �o7L�1I� City 1I il� yp ��L�t Pham l�vwhb <br /> C-5i Camr' r C-4 C,042. Dr•111,n Address 3632-a [. c4W...cbragya Grp'RS42hah*��41 PnoneC M! 638-1148 <br /> 1,1v�Gl.� <br /> c wl 1Subcnlr SE�a „c+e^nat3onar!_-Addre93, 7 I�;L�are ��► St�' Ity�L.�94f -PpcnsA IID $�I�o4od 2r# <br /> GIs Comdhatim <br /> r Tawnsl[ip �-� Range 6� 8er�mtl � <br /> WORK To N PKPSQRMMX <br /> N iA�LI f 13ORING (orr,GCOMOI3Ir,idYMOPUNCH,HAND•AUt.R,OTHM 11 DESTRUCTION (Chasse mm below) <br /> SOIL SORING# 11 PRE�-SORBSSURE GROUT <br /> UT <br /> WELL# V'!— �I� <br /> p,� GROU 7 SPMFFCATICN$ <br /> commeNTS' <br /> tYP£(1F� 1lVELL f1+t9T_4�L1,,—mm WEE go 40LON SPECIFI TION <br /> )(MONITORING XHOLLOW STEM DIA.CW BORERt�A Q MULE LTIPCASINGS Q Ml16Tl i.BVEI. WELL CA3lNR OIA <br /> 0 eXTTLACrICN D AIR HAMh$I," URNUN CASING THICKNIS h 40 <br /> TYPE OF CASING 13STBEL. %PVC U OTHER; <br /> iU VAPOR 13 MUD ROTARY pU;-TH OF GROUT SEAL$ „_TRF MjE jWri TO RF3 USED, gAUGBERS d KO�SE <br /> D AIR SPARGEr OZONE n PUSH POINT(GP ur CPr)GROUT SEUL PUMPED- X Yes 13 No (NOTE:MAXIMUM FRES-FALL DEPTH i9 2V') <br /> )KsOtL 8ORtNG Q HAND AUGER CRMT si3F_c11=1cATIDN3 ea* C.ev-90— <br /> II OTHER L _0 OTHER APPROX.BORING DEPTH StO b S %BOLTED TRAFFIC BOX or 13STOVE PIPE <br /> CON1DU=0R CASING PROPOSED tJ 6 (f YES,Rd spedficalfons in 4MMent sedton) <br /> Cc]mmEN" <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WOMNG HOURS NOTICE REQUIRED FOR INSMCTIONS, <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Winanoes,Rules and Regulation's,and all applicable Callfornte State haws. <br /> y;., agnrr+ai-�an+t� enc <br /> Punt <br /> iEI.ARTMENT USE ONLY ! O <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: Da*IWUS0 0 Iry <br /> - -0 <br /> App,Ww Acoepad av A,4�� <br /> Grout InVedlon By Cls6e Filial Irmacklon Ry <br /> t uWm lvspoet3olT ► Date <br /> COilAl41>Er 4TS I CON DfTI 4S- <br /> ACCOUNTIhtG GNL1fl AIQlL FAGf1 <br /> AB CO= FEE INFO AMOUNT RIEMIII F� CHECK# REC'D F3Y pA1'E ,� PrRiarr ISMME REQtlF. S INVOIOE <br /> G�a9,� TMJ -►NA7I'Vlwl ..._ C- 7 let#er of A�Itfial^rzafiicn to sign permit, >rturoochm�xlt doc__ 9/ 0l02 <br />