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FIFTH FLOOR . PAGE 02 <br /> 05/05/2004 06:45 2094683 PAGE; 03 <br /> 04/23/2004 14:27 2094683 FIFTH FLOOR <br /> ' WELL PERMIT PAGE: <br /> FORM LOP & IE: <br /> IT <br /> SAN JOAQUIN COUNTY ►dICTiGATI ON <br /> r <br /> ENVIRONMENT <br /> HEALTH <br /> ' 304 E.Weber,Tri rd Floor, Stockton, A., UNITIV <br /> —� <br /> p09} 468.3449 <br /> 1R 2 YEAR F M DATE ISSUED <br /> NON-REFU ❑ gLEPERMR EXP This a tiplcnis made in mmPllanct with ian <br /> Application is heraoy made 1D San Joaquin GaJPhrfor a pemfit to mnsttuct and/or Install the wok ne.�•ml Health DepaNnent. <br /> ofSanJcanulncounty 95 Assessors 1,,3`-,10-01 <br /> Joaquin Comb DevelcPmeni 7tla,Chapuu 9A'It5.3 and me Siandm S�,A � t5 Parml# <br /> S�c�Vc-Rirl ZIP <br /> ^ r?.7- .r 1r rOFF�.%(�1JEt cross Street Q•c>Ar0 City <br /> WetL Loogdon o�,57 t9 CITY f^.—.A''��p 'J51o�.Phgno# <br /> PROPERTY Owner �'".-, —Sfl'�_Addre9s p�q„u;,b 11-1510 hone#q_ t�` b3�-11(x9 <br /> A j u.il l�Address JZ Q++,EG C�O�•'+ CIh11i7dC�='-S RT ..rz,�Ire 7 <br /> Gsr COnti'achx --� 2Sf1 A- �p,G wace(, aneli a c1- ¢�r-••-� <br /> �e..--.c. o,.I>s ritY_55-- --- GQ <br /> ' Ce�,tlSub Cntr E" dress Ran R-15 �_Secfion�;�sJ_.-- <br /> Township �I K <br /> 6eS CogMlnates:X�—'Y <br /> ' d DESTRUCTION (dwose yp�bel Iw1 <br /> WORK TO6 PE RME4T pCVER.8oRE- DIAMETER_.._.-- <br /> Q NEW WELL I BORING (CPT,GEOPROBE HYOROPUNGi,HAND-AUGER OTHE a PRESSURE GROUT <br /> ;&WIL6OFUNG0 GROUTSPECIFICATIONS .---- <br /> DWELL# — <br /> ' 0*ODIar <br /> COMMENTS: <br /> ,.,,,EWy ly INSTAuA CONSTRUCTIC SqN Q�17 WELL CASING LII: <br /> Ii01JATI STS DIA.OF BOREHOLE$. Q MULTIPI-E CASINGS a MULTI..LE/ET. PVC D OTHER:__r- <br /> QMONTrORWG CASING IHIGISNESS TYPE t7F CASING: Q+ J- 0 <br /> a E(1FACTTON QAIR I�IAMMERlORIVEN TREeIIeTYPETO ITE USED: In AUGERS [ HOS JPVC <br /> Q MUD ROTARY DEPTH OF GROUT%E L OTE <br /> QVAPOR' GR13UTSFALPUMPED: )(Yes QNo (N : MAXII>AUMFR�'FALLDEPTNIS30 <br /> Q ATR SPARGS!OZONE Q PUSH POINT(GP rd CPT)GROUT SPECIFICATIONS STOV-.PIPI <br /> AOIL BORING Q RANO AUGER L(p/ Q BOLTED TRAFFlC BOX- <br /> 001HER: [1 OTHER APPROX.BORING DEPfH�. �f YESo listspedflcalims in mmm Int Wfion) <br /> CONDUCTOR CASING PROPGSED ....- .. . <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCHSS AGREEMENT OR ENCROACHMENT PERNIT.3. <br /> qg yypRICING HOURS NOTICE KWAulREP POR INSPECTIONS. _ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Jo aqui i <br /> Rules and Regulations,and all applicable Califomia State Laws• <br /> County0rdinart � t=( '�FtM�""�E <br /> so o I �- <br /> PtintName 4 DEPARTMENT USE ONLY <br /> �r <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S� S 20o s nt h \J I L„t <br /> WORK PLAN DATED: <br /> / , Q —Date Issue Dale <br /> Dade <br /> ApplteaGon ACCepted G?' '�``• Fnal Inspedon By <br /> Gmut Inspect=BY ENVIRONMENT_HJI.LTH <br /> ' Destruction hSPSCon BY Date .J — <br /> COMMBITSICONOTTTONS: QJ1GOp t IS'!- <br /> ACCOUNTING ONLY; AM# FAG1f - <br /> ' EST% etyDlC7i <br /> PE CODES INFO AEIDUNT RETtItIIrTED CHEGKA RECD BY DATE PERMIT!SERVICE p,EQU <br /> p �?°- �, I�s�+S 5-s -64 SR# 003— o <br /> 1's'1c _ <br /> 9 p oachmetlt doc 9/301A2 <br /> ' C-57 WC_„-WAIVER_- C-57 Letter of Authorimtidn to sin erTttifi_ _End' <br /> 1 <br />