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' 08/25/2003 16 36 2094583433 FIFTH FLOOR PAGE 03 <br /> , WELL PERMIT APPLICATION FORM <br /> vA�kx#�Ohli� - SITE <br /> HEESAN JOAQUIN COUNTY PU13LIC HEALTH SER MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-1=p) S UNIT IV <br /> 03AUG 22 PM 137 304 E. Weber, Third Floor, Stockton CA. 95202 <br /> (209) 468-3449 <br /> NoNnREFUNDAPPlicatiori is hereby made to San Joaquin County for a pem�to co struct andlor LE ES 7 YEAR Irk del DATE ISSUED <br /> Joaqutn County evela install the work described This application is made in Compllsnce with San <br /> �p ,rE Title,�hapa 9-t 1 i5 3 and the Standards of Sari Joaquin County Public Health Servioes,Environmental Health Dlvislon <br /> WEED.Lomaon 32s ltov. Aggeagors <br /> CrassStr2e! �'S City 15"6-n !?JR 45-�,-Parcel# D � 40.1 <br /> PROPERTY Owner Address ,6467 a c S � T1p�+SE1 F'honelE <br /> C-STCantractas C a Address aS0 GtyzlP- 1[,c}i G� Phone#C�tS <br /> C°multantISub Gontracto V Et..r� Address! 6tJ.l�C,. ..a Ct�_t, !2r( Phone#Cgtd_SbSN$7? <br /> GIS Coordinates X Y ,TowrishiA Range Semon <br /> ORIC 13E ERFORINE <br /> W ELL/BORIN C EOPROBE YDROPU AND,AUGER,OTHER-) 0 DESTRUCTION shoo" <br /> type 0 WELL#RING CPTH (]OVER-BOREelow? <br /> Mer Q PRESSURE GROUT <br /> OMEN I S Cxnut Spaciftrallons <br /> E OFVVELL INSrA TION TYPE CONSTRUCTION SPECIFICATtp S <br /> MU MONITORING p HOLLOW STEM DLA OF BOREHOLE— 24 MULTIPLE CASINGS?p YES tNO WELL CASiNGDIA <br /> 11 EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING 11 STEEL 1]PVC [I OTHER <br /> R Il MUD ROTARY M� OF GROUT SEAL,_�'jo' TREMIE TYPE TO BE USED 11AUGERS P10SE <br /> SPARGE >1(USH POINT GROUT SEAS,PUMPED ld5.Yeo [I No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> L BORING 11 BAWD AUGER GROUT SPECIFICATIONS �J e" eeA4"+- <br /> I(THERC'PT THER CP'�' APPROX BORING DEFrMRL, q BOLTED TRAFFIC BOX or qSTOVEPIPs=�lY: {�a5irt CONDUCTOR CASING PROPOSED? r tfi YES Kist SpaGfications heat <br /> MMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> ffhereby certify that I have prepared this application and that the work will be done 111 accordance with San Joaquin <br /> ounty or anC Ryles and Regulations, and all applicable California State Laws. <br /> 1Signed T'dlefCampny- env(r" <br /> dntName­ u Date d 03 <br /> DEPARTMENT USE ONLY <br /> t <br /> TOE MAP IN UNIT IV FILE,ADDRESS: 3Z 50„ W. Q rr,m_e r- L ati� -- <br /> RK PLAN DATED; 2003 <br /> pltcatlan Accepted By ' Cea rDate Issued ✓ Area 5'Lj <br /> r1t Inspection By Date Final Inspection By Date <br /> Destru -on Inspection By Date <br /> KU7N*nN(GONLY <br /> CONDITIONS C p 7"- o .0 AID# <br /> FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST$ INVOICE <br /> 301 89.00 99. o 0 0035,001 <br />�57 WC -WAIVER C-57 Letter of authorization to sign permit Encrodchment doc 9/27/00 <br />