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42" 02/@4/2005 14:34 2095224227 GEOLOGICAL TECHNICS PAGE 02 <br /> 02/04/2005 13:35 2094G$3� FIFTH FLOOR PAGE 02 <br /> ­'San Joaquin County <br /> ` `uviironmentak Health Department SITE g44 2 6 >~ast Weber Averse,3rd F16dr,Stockton,CA 95202 MITIGATION <br /> 68-34.45 Fax:(209)468-3433 Web:www.ojS*�"Webd UNIT IV <br /> .. NPi't T HEALTH Well permit Application <br /> RMIT/SERMCES <br /> M NON-REFUNDABLE PES EXInRn 91rUR FROM DATE"UED <br /> Appiicatitm is hKeby'mmde to Sark Joaquin County 1;br A Pam*to construct onOtAr install the work described. This applierltlan is m9de in Mrnpikance wltfi San <br /> jmquCounty ounty acv mem Title,Chaptw*11151 and the Standards of San Joaquin County EroAronrnant31140011h t]epartment. <br /> ` tissue's <br /> tiIlE41-l�aeaklnn 1�� - [.•=:� - Cross street `^� CifY 5 Cr c Za�r�� Pee+Csidk a' L�- <br /> } � <br /> Ow�PRO�o•r,a.� •S;r.c71D.t(• AMrass ]M 1n7T L, `�" q#, r('e.c�, T.1p Phonea�Zu,'y�•83 <br /> C,67 conb'�tor 't l�lCilt_7 ins c---ad`dle�s a .�Git}�J, ip � ic#I wrwrre9M ! <br /> t+ )sub Cnt&Cela <br /> GIG Cowd-makes,x} .Y Township _Rative- _Se�tial► 1[ <br /> tllPtaRlc?��Ia�F4RikEb: F <br /> u NEW WELL!13ORi1 G (OPI,OEOP DOSE,HYDROP'LjNrH,IiAND-AUGER,OTFAEW) p DESTRUCTION (choose type below) <br /> Q SOIL BORING# .)OWER-SORE. V �f <br /> d wFLL 6ati PecIF OAUT <br /> noNS Sk • 5 v p <br /> COMMENTS: q- Z 1 a, — �,rre�:a3- <br /> MONITORING i7jH4AMMEPJDRWEN <br /> OA DIA.O flREHOLP- p MULTiPLI=CASINGS Q MMMwLEVEL M�CAslNQ DIA. _ <br /> 11 EXTRACTION I DRIVEN CASING ICKNESS�`TYPE OF CASINR D 3TG�L. G PVC Q QTFtE4a VAPOR D1=PTH OF OUT TREMIE TYPE TO BE USES . p AUC3SR9 p HOSE <br /> p yi9R sPRRG J 02tiNE4rp or CF i�C3fttlU r sEAL MpEDt A Yes Q N4 [l�Ia�l'E:#IIA�tIIW1UM FREE-FALf.pEPTH�21o'yQ SOIL UOR114G GROUT SPECIN Q CYTHCR' _D OIftER_____ APPROX.HOiZING[?E [�BOL"C�C?1 RAFFIC BCDc or Q S3OVE PIPE <br /> # CONDUCTOR CASING P POSED(If YF,S,W N,edficatfons in Comment serton) <br /> Op11M11iEEtTEfS• E <br /> NOTE: OFFSITE BOPUIN`S REQVIRE ACCESS AGREEMENT OR ENCROACHMENT PERFAITS, � <br /> 1 48 WO.RI(ING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby cettly that I a prepa d thN applicatlop and thid tho work will be done in ol=ordance wkh San JoaquW <br /> County O an I guiations,and all applirable Calitomla State Laws. � <br /> gid x TilleACumparly. <br /> v <br /> Prim IVmane <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: y G <br /> WORK PLAN DATED' <br /> .I <br /> Ap Q4,2n fitGn*d sy pate Issued 7/ c, Asea <br /> &*U1 WpOdien AY, n...t Dete Z Final Ins'entien Bela ! <br /> Deslrudion Inspedion B Data, <br /> CpMa1E�IgYS J C:pI1Ea1T30EtI5' �" <br /> ACCOI►NTMNG ONLY: AIM FAUi <br /> M t:t'llDRA FM INFO) AMOUNT REMITTED CHECK* IMM My nATB PrPMT 18111VjMj i REQUEST dr INVOICE <br /> 3 so .ccs Oti qY9 , � SRX q to zg <br /> C-57-Z WCC,.-WATVEP�_... C-57 Latter of Authori=tion to sign permit`Encroachment doc <br /> FID 29"M.00I <br /> I �i <br />