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03/19/2004 09 07 2094683433 FIFTH FLOOR YAL*_ b1 <br /> •� +4.,, :r.Jv 4V7r00aY0J rt►-tH rLUUM PAGE 03 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> MAR' 1 8 2004 ENVIRONMENTAL NE&TH DEPARTMENT(END) UNIT IV 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH (209)466.3449 <br /> PERMIT/SERVICES <br /> Apphrawn Is hereby made to San N Mw COW•1 YENt FROM bATE OWED <br /> CaunK far a permit tri eonstnid andkr rrrstall the work desalted fire a <br /> ' laaquln County pave t'rt ppAcepe is made En carlpfiance with San <br /> lOprnen lie G�apter&1715 3 2rtd 1hC Stau7tldraS 0(San.rO6glJrtf County EnvNonmental Fie211h DspartrrenL <br /> COU TI 4A Il4rr CAKACr� Assessor'3 <br /> wELI 4ocalror► S 4. Y cmj iv Cross s�E.w�B E h 1►y city S ac TO M zv 9S Parrxt# 12 002. <br /> PROPERTY 0►veypr FAcll.1 SS rr Addmsa ITU t.SCOITS AN Imo, C,ry, Ahcnell <br /> ' C-57 Con <br /> LM <br /> P1SCk I:NYI oM R 399 S E 'S Lh6E S PRt �S 95251 <br /> ConsWtantlSupCntr AAMhG-L Addref P•0 80 9 I:CAM[H4 <br /> C� Lv#R&5656 Prpnea Sl 35 - 25Q <br /> ' GIs Cowdmatas X F_4 ENT'Y t IRE Township Rutpe Seellon <br /> WORK To BE pE WORMED <br /> ' B NEW WELL/BORING(CPT GEOPROBE,MYDROPUAfi:Fl,HlWD-AUGER,OTHtR-) 0 DESTRUCTION GehmW We below) <br /> NSOIL BOf7 Q# G• -5 G-6 <br /> �WELL# [!OVER-BORE; <br /> 'Other Grout �� 13 PRESSURE GROUT <br /> COMMENTS 3 0N-5iTF 0 Y A0b Q luNG 0 FIR G-A OV Rb WA R <br /> TYPE M V14ELL us ALLATx*im tUCTUM SPECIFIgMONS <br /> 9 MONITORING Q HOLLOW STEM DIA OF 0ORSH0W til_[MULTIPLE CASINGS'1;MULTI-LEVEL?0 WELL CAVNG DIA NA <br /> 0 EXTRACTION (I AIR HAMMV;UDRIVEN CASING THICKNESS__M_TYPE OF CAsNG. p STEEL R PVC a OTHER MA <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT 4E10.E.TU=3O t TREM1EE TYPE TO BE USED I AUrEIRS g HOSE <br /> 0 AIR SPARGE 1 Ozone g PUSM POINT GROUT SEAL PUMPED Dyes K loo (NOTE' MAXIMUM FREE-FALL DIEPTH IS 30') <br /> ' L BORING D HAND AUGER GROUT SPECIFICATIONS NgAT t1min <br /> ER A OTHER � __- APPROC.BORING DEPTH r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 'COMMENTS CONDUCTOR CASING PROPO$67 0 (if YES.first eperAeawns here) <br /> ' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMI S. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTf NS <br /> hereby cerft that I have prepared this applMatlon and that the work will be dome In accordance With San Joaquin <br /> '.ounty Ordinances,Rules and Regulations,and all applicable Calibrnla State laws. <br /> jvgned. TI o o ,y Cot�svkrhlyT�-RAMkIt _ IVvtRot�ME�1TAL <br /> �nnt Name X17 S M G-E. Date <br /> QEPARTMENT USE ONLY <br /> KITE MAP IN 11NfT IV FILE,ADDRESS' 130 N• HvNTlilt SZ t E S 4 C lC 0 N CA <br /> 'CORK PLAN DATED:_ M A_�ry H t1 I Z Q G <br /> 'yplrrauan Acxp[ed BY � Dota Issuw _�1rgB.14 5 q <br /> rout Inspedlon 8y oate Final Inspedlon By Date <br /> rres7ruclon 12m!SLm By Dabs <br /> orarlleHTs J Cap�tprflpkSrnal'I 12 LLLgU.j& <br /> AIXOUMING ONLY, AHkF ee <br /> 'Pis CODES FEE INrd AMOUNT REMATItIEd CHECK#r RECD BY DATE PGR>IAIr t SFR1 M REQUEST/ tNVOWE <br /> of 89. 00 q. Do 0 3 z <br /> WC-WAjVER-- C-57!.otter of Authorlsation to slgn perm+ Encroachment doe 8/29102 <br />