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03/02/2004 14:07 209-579-2225 MODESTO ATC PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E, Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDAIBLE Pj8 rr EXltRE3 1 YEAR FROM DAT6 ISSUED <br /> A00IIC3tt0n It hereby made It San Joaquin Cot:ntyfor a permit to construct and/or InstaA the work deacrtbed. Thia apolicetten to made In eatnplianee with San <br /> Joaquin Count/Deve(opment 71le,Chaoler 4 115.5 and the 312ndarda of San Joaquin County Public Heallh Services.Environmental health Olvislorl. <br /> Asses-7 6-�S tleft< F/wtn?`rS+ Sf (A114M+e� rw TS30 Amiss ors <br /> WELL Location Ctosa Street �� City � s�,. 21p Paroelp <br /> PROPERTY Owner D"• A-A'. 619-Vt� Address ?-& 8A0 145-s- City 7--%rY Zip IS 172 Phone*L?2CR 3G'4t5q� <br /> C-37 Contractor G,-ett A,,'W-gf t't_Addnsal56 Mewc Rj� city&,WWt ZIPjt$'t3 Looe f6W7 PhoneK CttS��/�-Stas <br /> Consultant J Sub Can tractor Arc 14sJer,�ltf ZM AddrestlF•��t ��Y► it✓�_Clry sf*J� Lie# PhoneN���J f fit'1a�1 <br /> r— <br /> Gt!Coorol%atsr.X Y Township Range Sactlon <br /> WORK TO al PERFORURDt <br /> .NEW WELL P EOPROB=-,HYDROPUNCH.HAND-AUGER,OT14ER-) D DESTRUCTION(cttooss type balcW) <br /> Ss IL ORING x D OVER-8CRE <br /> Q WELL II PRESSURE GROJT <br /> *Other* Getout Spedgeatlone: II Ca eiI <br /> COMMENTS: d'.ri'"S 4v /?Q ,(44f , a 7A-f;/ i, ♦hi.6v.9,100, T _2 wlrp'j4r; <br /> TYPE OF WELL -�tNlTALLATIDN TYPE C0931SU00N SPICQI(CATION! <br /> 0 MONITORING 0 HOLLOW STEV DIA,OF BOREHOLE / rr MULTIPLE CA3iNGS7 D YES Q NO WELL CASING CIA:OV4_ <br /> 0 EXT"CrON D AIR IiAMMERJDRIVEN CASINGTHICKNE43 N4 TYPE OP CASING' p S7EEt. Q PVC D OTHER' A/A <br /> Q VAPOR D MUD ROTARY Oj:PTH OF GROUT SEAL TREMIE TVP,YO AE USED; ()AUGERS <br /> Q�d9E <br /> tl AIR SPARGE PUSH PCINT GROUT SEAL PUMPED; D Yea D No (NOTE: MAXIMUM FRET=-FALL DEPTH 19 301 <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> Q 071-IER; 0 OTHER APPROX.BORING DEPTH 12 D _D BCLTEDTRAFFiC BOX or p STOVE PIPE <br /> CONOuCTOR CASING PpoposED9j�d _,(ItYES,list speofcations here); <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECT OR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED IN3PECTIONS. <br /> I hereby certlty that I have prepared thIs appllcatlon and that the work will be done In accordance with San Joaquin <br /> County Ordlnancee, Rules and Regulatlons,and all applicable CalHornin State Laws. <br /> Sloned x/t/arr /1 TIUelCompany SY4 ie�e &m6oj r>A/,-0T-C rre. <br /> PnntName lvta'1��ttn �Hrrs7�7rMN pats 3 -- � - �y <br /> DEPART Y <br /> SITE IAAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Appllation Accepted 8y Date Iaaued Area <br /> Grout Inspecuon aY Data Flnel Inspor-don By Date <br /> Dastnx on lnspaction RV Data- <br /> COMMENT!t CONCITOONl: <br /> ACCOUNTING ONLY: AID* <br /> PE COOCSFEE INFO AMtOUNr REMITTED CHECKS RECTA aY DAIS PERMIT ISLIRVICE REQUEST d INvoICE <br /> C-37_ WC,"-WAIVER C-57 Letter of authorization to 519m permit_ Encroochrneit doc_ 9/27/00 <br /> 2 -d STGSETESZ6 - uepTOM RJRW dTS : IO tr0 20 Jew <br />