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' 07/07/2003 10 45 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DI=PARTMENT (EHD) UNIT IV - <br /> ' , 111 2003 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH (249)468-3449 <br /> PERMITJSERVICES NON-REFUNDABLE PFAMrr MCPtRES z YEM FROM DATE ISSUED <br /> ' pphcabon Whereby made to San Joaginn County fpr a permt to caistruct andler Instatf this work desanbed This appricaLan Is made in cmvianae vft San <br /> ]squid County Development T'i$e,Chapter 9.1115 3 and the Standards of San Josquin Cour*Environmental Heafth Deparkrnant <br /> Amesmes <br /> WELL tombon 3H 7 S E 1 bII Geos Street 1� T City si 71, TSo(-(o Parmig <br /> tRCDP RTY Owner Vein be 20 1 _Actdr+�ss •�O x �� �, Gty�ZIR_ �t Phase 'tl {{ <br /> 7 Coniracter �-` Address --- City 2Ip W a'hiane �C c3� I i Val <br /> ' onsuAwdISub Cntr $ Ga Address t3`I_ Ska. ty Sly— U Phone3F aDg <br /> t,v��w►7+rl�t 1 <br /> 15 Coordinates X -Y Township. _______Range Section <br /> ' ORK TO BE PERFORMED <br /> NF-W WELL,l 90RING(CPT,CEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-} C DESTRUCTION(choose type below) <br /> 0 Stilt.BORING# G i 9 03 1]OVER 80RE <br /> SELL#ririr- 1K.- mW-8 m 41-91 mw-f 2 O PRESSURE GRO r <br /> Grout Speaateons <br /> ' DMMEWS ,it%Cf *-n pet s t A .edl For <br /> apt;OF Y_MELL INSTALLATION`TYPE gmSTRUCTiON SPECIFICATIONS <br /> MONITORING OLLOW STEM Ol,4 OF 6OREHOLE f r MULTIPLE CASiNGV*ULTI-LEVEL"U WELL CASING plA..-. .___ <br /> OCfRACTION Ia_AIR HAMMEf;4vRIVEN CASING THICKNESS TYPE OF CASING []STEEL J]PVC )0 OTHER. <br /> VAPOR d MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE LIED hl AUGERS U HOSE <br /> SPARGE I OZOne aPUSH POINT GROUT SEAL PUMPED p Yes p No (NOTE' MAXIMUM FREE-FALL DEPTH IS 301) <br /> IL 13OMNG U HAND AUGER GROUT SPECIFICATIONS. <br /> 'ITHER. fl OTHER APPROX BORING DEPTH n BOLTED 7RAFi-'IC BOX or Q STOVE PTFE <br /> ' CONMICTOR CA ING <br /> PROPOSED? (if YES,list specifications hem) <br /> Omm 61jeo&:4v 'n -Alt <br /> 1,.dct K Eva, <br /> t Ozoo—a"& Amvvaf le <br /> t NOTE: OFFSITE EORIN S REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNrr IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL ReQUIRED INSPECTIONS. <br /> tereby certify at I have prepared this application and that the work will be done in accordance with San Joaquin <br /> ' )unty lO Rule and ulattorls,and al appliCabIS CalifU Mia to LawS. <br /> fned x T�elCampany 61YlC Geo t'.1Iti a <br /> ' nt t-t`S '►��ter fl• 14 e r Date 10 �u n c. R 00 3 <br /> — - DEPARTMENT USE ONLY <br /> TE MAP IN UNIT IV FILE,ADDRESS; 814'7 Dorado i5±r-ee-i- <br /> ORK PLAN DATED: Apid I q, a OC z <br /> plimbon Acceptad By. 1/LC�h r I'& a r..- Date'so ted Jul% 1. 14063 Ama 1461 <br /> ' sat Inspection$y Cate Final Inspection By �taee <br /> strucwn Inspection By Datta <br /> immEws l CoNDt mss al, <br /> ' .Cf UNMNG ONLY AID# <br /> a 93 FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT J SEFMCE REQUEST 0 INVOME <br /> ' 3Sa 89. 0689. 00 Qty 34475 <br /> 57_„_, WC--WAIVER,,,,, C-57 Lettex of Authorization to sign permit Encroachment doc 8IZ9102 <br /> I , <br />