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JANz10-1999 11:19A FROM: Tr 42094683433 P:2/2 <br /> WELL PERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY SITE <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) MITIGATION <br /> 304 E.Weber, Third Floor, Stockton, CA., 93202 UNIT IV <br /> (209)468-3449ExP"S ATE <br /> APPlicatim is hereby made to San Joaquin county for a to construct and/or I <br /> 'kOgwn Courdy D�olopmern 11tfe,ChaM&-1115.3 and the S*derds of San Joagt>Itt Cho t�0leswbed. "his pppiicatlon is mado In apmplianoe wph Sart <br /> 46Ra 6 �..eR.,ti�! l�, wrtyErvArorrmerntal Health Department. <br /> WELL Location 14 146 /U v. IL..S9 ,Ace%*I 017-09o-62 <br /> 1!Crow Street s.G.IIBfI10-6 Ciy_AcA•npo- 2ipPROP94210 p roadt O(7-0g0-3S <br /> Owrw, pT1( ►d.e a.E O <br /> Ownpr � �ys�?'� Address �o Ma�� R'�, �erLe�srrrr 4,:/S. — Iq2S`/i <br /> CKy �s - zip 4`�oL2 phone# N <br /> C�7Contr 64mb6- oa�UwNt drfss 4�o G4o,,,c f?J. Cft N.o�r c�Zl 44s&; 44 <br /> y p Uc* Phpne# 0125 <br /> ContlnAtant sub Cntr A k$��ee+L P. n�S A710-at k3 cttyA ,L.,juak C 21110 <br /> Phone#.S <br /> (315 Coordfmataq;X ,YNm . _.TownshipN Range 1 t: <br /> 8 secwn 31 <br /> ,ffNFW WELL/BORING '� EOPROBE,HYDROPUNCH.MANE)-AUGER,OTHER-)SOLOING p DESTRUCTION (choose <br /> typo below) <br /> Q WELL# Q OVER-BORE. DIAMETER <br /> a"Oew -$'PRESSURE GROUT <br /> COMMENTS: ROUT SPECIFICATIONS <br /> TV IN TIOfV 1 li�N SpMP19AIMS <br /> O MONITORING p HOLLOW STEM DIA.OF BOREHOLE <br /> 4 4.8 each 0 MULTIPLE CASINGS 0 MULTI-LEVEL, WELL CASING DIA: <br /> ij EXTRACTION a AIR I AMMMORIVEN CASING THICKNESS <br /> Q VAPOR TYPE OF CASING: 0 STEEL PVC Q OTHER: <br /> (]MUD ROTAROTARY DEPTH OF GROUT BEAL a&(kms TREMiE'TYPE TO BE USED: n AUOERS <br /> 13 AIR SPARGE/OZONE GUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q HOSESOIL SORING GPr D HAND AUGER S No (NOTE: MAXIMUM FREE-FALL DEPTFI I8 30') <br /> GROUT SPECIRICATION3 <br /> D OTHER,_ _a OTHER_ APPROX.BORING DEPTH_ Ao ffg 6r- 11 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,fist slnoci6c0tions in cornrnent section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances,Rules and Regulations,and all applicable Califolmis State Laws. <br /> Somd x TNwtCvmpany� <br /> Pnrrt Name m <br /> ONLY Date 10_28-03 <br /> DEPARTMENT SE <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Aoae ted IsWed _�T„�� <br /> Nmbmm 1 al Inspection By_ Date <br /> Data <br /> COMMEWS I CONOMONS Is S am t9A.6 1 o r< <br /> d <br /> E'CNp ONLY: A1D# �`^^” � 11 r <br /> 7 5 ks FACM <br /> FEE INFO AMOUNT REM�D CHECK# C' � DATE PERMIT I SERVICE REl11JE8Tf1 INVOICE <br /> g O� 2,Io7RBL2=03 sR# 3 -7 1--�- <br /> C-57 WC-WgII/ER_ C-57 Letter of Autho zatl sign pe mit Encroachment doc_ 9/30/02 <br /> I <br />