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11/20/2004 09:50 209-579-2225 MODESTO ATC U MED U gfE��r a�)111,'f'AGE---�03 <br /> ,I _J <br /> DEC 12004 <br /> WELL PERMIT APPLICATION FORM kNVIRONA r ,g , <br /> SAN.1oAQLRN COUNTY EHo PER ; GA7n,0 <br /> ENVIRONMENTAL HEALTH DEPARTMEN { ) UN1'�'1V <br /> FILE 304 E.Weber, Third Floor, 9toakton,CA., 96202 <br /> (209)461+3449 <br /> Application is hereby nude to Sen Joaquin aut>fytor a Paxxnd to oorrtruat and/or IIyleHths,rora daecrfbed. TtT eW rtyoDe a In compliance with Sen <br /> .ioaauin County Oeverowy—d Title-CAepter 9-1115-3 end IV Standards d San Joaquin County Enwrannenss <br /> x,453 [ Pa2�43soo4 <br /> WELL.Laeatlon 1 S <br /> Owns E *� I��i Qe� Cruse StroetY — <br /> PRartaTrar`+ <br /> l ��,,,3 ♦r ZIp9aSS Phw�N ' <br /> �K ___Atltlrraaa xso64 Vrk' srI' c <br /> C-ST ConVsctor Ur.J...J Da:�4� Addnasa fir!RKw,rt'� - cKr — _ '�IDO�!Pnor��v 'f�O <br /> Consultant l Sub Cr_ALC r'C 4'1 9ATa i Addreac 1 I¢L"NhAad C1tyLkJ1 – <br /> we CotAvtas:X _.Y .To vn hip •r Z S RanQa 5 Section <br /> ort <br /> Y'NEW WELL/aORING (CPT, OPR �YDROPUNCH,HAND-AUGER.OTHER) I]OvERg-ems DESTRUCTION type Delow) <br /> 401L t30RlNtS N s41-eaWORK TO N MOM -__ t;S G PREssURE GROUT <br /> Q WELL N GROUT SPECIFICATIONS <br /> G <br /> COMMENTS: <br /> TYPE OF WELL <br /> Q MONMORING Q HCH-LOW STEM DIA.OF BOREHOLE 1" 0 MULTIPLE CASINGS O MULTI-LEVEL WELL CASING OLA: <br /> p EXTRACTION Q AIR HAMMEWDRIVEN CASING THICKNESS TYPE OF CASING_ Q BTEEL G PVC BOTHER. <br /> (I VAPOR G MUD ROTARY DEPTH OF GROUT SEAL'6 TRSMIE TYPE TO BE USED: GAUGERS G HOSE <br /> Q AIR SPARGE/OZONE)OUSH POINT W or CPTyGRCUT SEAL PUMPW: Q Yes p No (NOME: MAXIMUM FREE-PALL DEPTH 13 30') <br /> WM BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: n OTHER APPROX.BORING DEPTH T G BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ;VQ (Ir YES,W speefA melons in cormierd section) <br /> COttaMt wn: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> I hereby certify that i have prepared this application and that the work will be bone In accordance with San Joaquin <br /> County Ordinances,Rules and Regulations,and all applicable CaRforrile,State Larva. <br /> slynw x �Q ( I eQTltwcano.nr 1: � �i��c <br /> Prat Nerve C�N�f✓1 C�.�.��Iy�1eS� Date / lAq�� <br /> DEPARTM IJT USE ON�LI <br /> SITS MAP IN UNNT N FILE,ADDRESS: 15 E. 67-11 L ► n e R oa d <br /> WORK PLAN DATED:A, p r i I 19 . "64, <br /> Appricipbon <br /> Q4- <br /> AApricipbon ftcaptad L M +ney Ota Iswed�t 1 -0 Ar.a43 <br /> crocrt Inepectfon By �t i z• L•o Final irrp.etlon Ery ` Osla <br /> /Z' - z - 0 5e <br /> Demck" coon By oab se-1 —2 --3 <br /> COMU MTs I COMDrTKM: AAjtigr-Pv%&n+ <br /> ACCOUNTING ONLY; NDN FACS <br /> PE CODES FEE INFO AMOUNT REMITrTEO CHECK a RWO BY DATE MWIT!2115"CE REQUEST N ' iNVOtca <br /> 3,50184,00 req- 0b SM 0040 52- 1 <br /> C-57_ WC_WAIVER_ C-57 Latter of Authorization to sign permit_Encrocchment doc_ 9/30/02 <br /> £OOZ SuTTTTJU PJwmP00M OOCVtL£LOL XY3 Tt:60 t,00Z/0£/TT <br />