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11/3Oi2904 99:501 299-579-2225 MODESTO ATC PAGE 02 <br /> cc <br /> DEC <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN .IOAOUIN COUNTY kNVIRON wryVlIRI.ATiQN <br /> ENVIROMM04TAL HEALTH DEPARTMENT (EHD)PERMI Maws <br /> FILE COPY 304 E.W4Eaot•,Thl(�Floor, <br /> 4663449 Stockton, CA.,86202 <br /> Oapdcatlon Is Mnsby made to San Jk�aauin County fora Pee *b�oonsbuctg RM gram"M the vso+k desalted Two motesson is rrwde kn eatnptisrxe with San <br /> )oequin Courtly Oevelapnwnt <br /> of san Joaquin Coi ly E-"nmw+tsl HasM Doper""". <br /> Title,Ctwptsr GA 115.3 and tl a a <br /> WILL L WOW f' 1T A,+ eShroa saaatg�++�k'"B C)h►• -----� Peroalll�— <br /> • <br /> ►�►ERT� cny_T�.,r, zip!JfI-�Phone�e >Lt. <br /> -. <br /> mar (�•J .se1T AdEfese C�.+ ?S�r .du <br /> C-a?Cantractor� s+e�DrM. Address 'S3o �Re"��✓ CNY Zlp.-- MOM PhaneA '430b <br /> ConeuJlamt/Sub Cr:tr—Aff eal'�, L Address 110 to-or N-�+r sr.a C�„t�It_L�� rt PhorreM �,-sq�►-2221 <br /> GIs CaordYwles:X Y Towr1W*—T ks Ranpe R 5 F —Sedbn �6 I <br /> E PQEI�Q�ED: '�'-•� <br /> NEW WELL I SORIAIG (CPTROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION (Choose type below) <br /> PWL BORING 0 :a 1 p OVER-aoRE. OMWTER <br /> a WELLQ PRESSURE GROUT <br /> D. „r GROAT SPECIFICATIONS- <br /> COMMENTS: <br /> M29atfilL6 <br /> 0 MONITORING D HOLLOW STEM Ott OF BOREHOLE_1L Q MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION Q AIR HAMMERIDRIVEN CASMIG THICKNESS A6! TYPE OF CASING: Q STEEL (I PVC 0 OTHER: <br /> D VAPOR []MUD ROTARY DEPTH OF GROUT SEAL6 TREt(E TYPE TO BE USED: Q AUGERS C HOSE <br /> D AIR SPARGE!OZONE�'USH POINT�Dr CPT)GROUT SEAL PUMPED: C Yea C No (MOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> 'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER: n OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX ar Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (If YES,uu spect6oaWns In oommenl section) <br /> COMMINTY; <br /> NOTE: OFFSITE SORT NGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4S WORKING!HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the worts will be done in accordance with San Joaquin <br /> County Ordinances,Rules and Regulations,and all applicable Caillornia$tate Laws. <br /> ftned Tftweampony-- <br /> PAM N.. Iree «res'r 'E_ CAAtIftla..,a+z Dees <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: yen SGran-L <br /> WORKPLAN DATED: ,AQrJ 16� 20Q4 ULife R� <br /> APp tlort Srn Y DNe house Mae 14-51 <br /> Grout MPewon a Date /s•2_Q ei Impectlon By�` <br /> Destrvalon lWoobon By Dees <br /> COIiiMVITa 1 C0110ITIONa: ` ` S <br /> ACCOUNTING ONLY: AIDO FACA <br /> Pa CODES FEE INFO AMOUNT REMITTED CHECK M RECD BY DATE PERMIT'/SERVICE REQUEST a INVOICE <br /> 350 1 89.00 89. 0 d SRO 00 0 5 2 <br /> C-57— WC-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br /> Voof BUTITTia pUBmpooM 00£t$L£LOL VVJ Z3:60 b00Z/0£/IT <br />