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03/01/2002 11:24 209467' Q AGE STOCKTON V4GE 02!02 <br /> 03/01/2002 09:49 20946 3 FIFTH FLOOR 0 PALL 01 <br /> WELL PERMIT PPLICATION FORM SITE <br /> 06PI SAN JOA UIN COUNTY UNIT VTIt]N <br /> ENVIRONMENTAL HE TH DEPARTMENT(EHD) <br /> 304 E. Weber,Third Floor Stockton,CA., 95202 <br /> (209) 68-3449 <br /> ryONF�1NDgeLE PERMeJ$E,T t VEgR FROM DATE 133�UPD <br /> piicatlan)r homby made to San Joaquin County lora pdmJl to oonalruut and/or ins+11 the vgrk dcaaipud. This apoeatlon is made In compliance% t San Joaquin County <br /> velopmrnt Title,Chapter dq I v%aond tho S nderde of San Joaquin Ceunly Epvi nmemal HWlth Deperttryant <br /> [ � f Assessor's (�c ogo_cs <br /> ILL Locatidk �pof^ O Ctdm Street Cit/ S7'I� Zip PareelR /— <br /> ovERTY ownerMiC�ac! NGUYCa Addreee nWd de I AA A Cot &S 3ase zip 4^j✓3gphoroayoig S$E-701, <br /> .7 Ganlra,,a, l,_rycz�AAS s?.�Art(�aa,r.�a 37 S(+w tz� G;ry SFT- �pgstrr Dcn��o�'�Plwna,r�9-`/�7/Gf7G <br /> nsultant l Sub Cantroaor Air�V0.n C¢d' GZU Address S e. City �?Ti: _Llok PYanrtl! ��"7-��Qb <br /> I Cowdineles:X .Y Tmvnship Ranpb Sectlon <br /> )RK TO BE PERFORMED: <br /> IIEW WELL IBORING(CPT op-LL-70 <br /> B HYDROPU tC _H2 D-AQER 0TH R') p DESTRUCTION(choaso type below)OVER <br /> BORE <br /> RING 1� 0 PRE&SURB GROUT <br /> her. Growl pecificerions , <br /> IMMENTS: <br /> 3E O INSTALLATION TYPE CDNSTRU0 CIRCATIONS <br /> IONITORING aHCLLOW STEM OIA.OF SOREHO Z'$/a MULTIPLE CASINGS?AYES *NO WELL CASING DW:_ <br /> XTRACYION Q AIR HAMMERJDRIV0N GAZING THCKNES TYPE OF CASING: pSTEEL OPVC 0OTHCR:__� <br /> APOR QMUD ROTARY DEPTH OF GROUT EAL "1'p TREMIE TYPE TO BE USED: DAUGERS V40SE <br /> IR SPARGE XPUSH POINT GROUT SEAL PUMP R: 0 Yes )(No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING U HANG AUGER GROUr SPECIFIC A IONS' <br /> THER7 BOTHER APPROX.BORING OEPTH ':7S - tiEOLTr0TRAPFIC5OX or OSTOVEPIPE <br /> CONDUCTOR CAst GPROPOSED? 00 (DYES,rst spadfimttans here): <br /> IMMCNTS: G .h 0. Sava I T37't.J ryr2�'+trot r�! 7-0 <br /> NOTE: OFFSITE BORINGS REQUIR ACCESS OR ENCROACHMENT PERMITS. <br /> GALL TME UNIT IV INSPECTOR 48 WORKING H URS IN-ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> ereby certify at 1 have prepared this application and that the w rk will be done in accordance with San Joaquin OOOnty Ordinances, <br /> I®s and - ali ap 1' ble Calif is State Laws. <br /> d 1 <br /> retlz TiuelCo Pant Grltlr rtlA Y'iG^rp41 S�L'Ga(' '/ <br /> 1 Namu <br /> Data z_&�-z ,�D) <br /> DEPAR ENT USE ONLY FEB 2 6 ZOOZ <br /> 'E MAP IN UNIT IV FILE,ADDRESS: ' NT HEALTH <br /> IRK PLAN <br /> DATED; <br /> Iiratlon A=pW BG/ AL,lasu <br /> al �/ <br /> ,tInspectionBy Date Inspection <br /> ERVICES <br /> By Data <br /> (ruction Inspection By Date <br /> AMENTSI CONDITIONS: <br /> .COUNTING ONLY: AIDA' FACq <br /> I CODES PEE INFO AMOUNT REMITTED CHECK a RECD BY DATE MMTr IAHRVICE REQUEST n 7NYOICE <br /> �o) <br /> C_!57 We _-WASVER_ C-77 Letter of Authafizafion To sign permit_Eneroachm nt doc_ 1/25/02 <br />