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Feb 24 04 10: 23a Wayr woodward 1 -7 -'-374-5677 <br /> 02/24/04 TUE 10:10 FA.0 SIB B�,•t90o URS I°" 2 <br /> 14002 <br /> 01/20/3004 10:24 2894683493 FIFTH FLOOR PAGE 02 <br /> -'WELL PERMIT APPLICATION FORM SITE <br /> lMITMATION <br /> FEB 2 7 2004 SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> ENVIRONMEfd i HEAL 1304 E.Weber, Third Floor, Stockton,CA-, 95202 <br /> PER111T/SERVECES (209) 468-3449 <br /> W0%: r- D BLE PERM F�PIAES 7 YEAR FROM PATEMWED <br /> Application iS hefeby mada to yah Joaquin County tar A paenittu conslnret�nl , rnet�ll the work d"CACed- Thlc apPGollon is made In menpllanee with Sart <br /> Joaquin County 0ewlopmeni Tufa,Chapter 9-111S.a arm,Ate Slradardt of Sen Joaquin ceunry F-mironm "al Health mpar" T Assessors <br /> ALL Lao4an SO1 lU. G W4N (_A. Cross Sbeet% "utcAnotiL.SCity L Oel(1 Z+p (�j��-y�Pat�bF <br /> pROPeRTf Owner�C� Addrase Po V a, SO 5 7�[yp ,GW CA +P�-!5 Phone <br /> r--57 cam"dorLUD-0o� LI1 ZS�ess�U�oX 33(o City3.rv=� �-y1 •Lkc#�r(?D �_Phane �O�• f1'I�Ob <br /> conso{unt/Sub Contracmr_ U Q S C1!t P• address��2 atGy��k-S Clty�ALtor�ttss� PhoneC 5l[a -�fit-ZctoQ <br /> GI5 Coordinates:x ,Y ,Township„_,_ Rango Seetlan <br /> WORK TO BE PERFORMED: NwC7ESTRUGTION(awe—"below) <br /> p NEW WELL I PORING(r-PT.GEOPROVE.H'y0ROPUNCki_MAND-UJGEi�OY14EXI ZPVER_�E <br /> Q RW SOIL BDG# 0 PRESSURE GROUT <br /> d WELL# Gcout 9pccilleatiana; <br /> 'Other: <br /> coMMFNTS: <br /> rypE r1F 1NE1.L INSTat LJ►TIOW 1Yt'E CO 57 t Fl D 5 rf <br /> ` MOYITCRING �G )S*LLOW STEM DIAL OF DOREHO "'1 it MtJLTIPLE CASINGS?()YES XNO WELL CASING DW <br /> AL <br /> 1 AIR F�AMMER PFUVEN CASINGTHICKN55s St 40_ -TYPEOFCASING: Q STEEL PVC Q OTt{ER: <br /> �IJAPOR g ❑MUO ROTARY DEPTH OF GROUT SEJ'LL T'REMIE 71?E T413E USED: Q AUGERS Q HOSP <br /> D AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED <br /> Cly.. 13 No (NOTE:MAXIMUM FREE-REFDEPTH 15 30') <br /> Q SOIL BORING p HAND AvaER GROUT SPECIFICATIONS <br /> p OTIiER: 0 OTHER - APPROX.SC RING DEPTH _ _11130LTED TRAFFIC BOX or 0 STOVE PIPE <br /> Cpn1DUCTOR CASING PROPOSED? (it yFS,list spedficafions hent): <br /> 'COM1yEt'i7Sl <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 413 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that 1 helve Prepared this appileation and that the work will be done in accordance With San.ioaquin <br /> county Ordinances.Rules"d ReaulaIll s,and all applicable Cal"ornla State Laws. <br /> ,•� � nnercanivsny s�4�N�L�3 �✓�G!!�<�'�'.�y ��i�G�-%r� <br /> Signed X <br /> pAr-t NamcPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, DRESS: <br /> WORK PLAN DATED: a2 S 0 <br /> nate I:stleC 3 ( 6 qAmb <br /> Appltotion Arrxpted Hy Q r`r Det <br /> Dat 4( Uo V Final klspeotian By_ s�• � �— <br /> Graut IrI4pvGtian By <br /> 0estrydlon Inzpection 9y Data d / <br /> COMMENTS/GGNDMONS: W A rrQ/L I►'lW 1)t Ltl - l�yq_ <br /> IPFSt <br /> GC.OUNnNG ONLY: <br /> AiDa a+� �f <br /> cOGES FEE INFO AMOUNT REMtTf� GHl?CKr R>sC'OBY GATEPE"ITi SERVICER�q D <br /> got 0 o <br /> G-57____ WC� WAIVER C-57 Latter of Authorization to aign ptMjt Encroachment dam! <br /> 1/2 <br />