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11 ©'Z10t ZUU2 514 eZ5 20 y4 h J02,02 f 02 <br /> 433 FIFTH FLOOR P GE 0 <br /> 1 <br /> 10/14I201�2 13 81 2099412,974 rAGE 10 <br /> '11 2094ZB3413 FIFTH !'I-ROP PjzGE 02 <br /> WELL FERMI-r APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EMD) UNIT. IV <br /> 304 E, Waber, Third Floor, Stockton, CA , 95202 <br /> (209) 468-3449 <br /> N0 - F E3AR LR r i YIElAa PigATE <br /> Ap�1,�tIpT1 I�harebyrrgy4 to San Joaquin Cow*for a perrnil ea nmrlstruct ancVor inaffilI(he work'1eAeribmd Thrs applimt[an ja rrada Irt compliance with Sar: <br /> _Oaquin CauNy 0eve1opmei1VM0t,ch2*r all iS 3ard o1 Sart Joaquin County Envrronr imw Him U, ❑iiit <br /> tWELL 1T41M00n iii cross bleat 3 11i CA/eltY �FkcEnLisars <br /> PROPERTY Cwnier dtl^asta'✓I�,d�_�y(. ci�.�s�.�„T�.��t}r Zlp��['�fPhona# <br /> C-*7 r0"BCt6^-- �..« DR1� dream 0 -b..uc G[ry A Lc#` a�l��Phane �a _ <br /> Consulbnt/sukr cntr Glrt�Es _ Glry Vc# Phone4 <br /> GIS Coordinatea x Y Township Range 3ectlran <br /> WORK 19 11 FLREgmim <br /> )IQrJEW WELL t BORWG rCt-r GEOPROBt�,HYDFRORIJNCH HAND-AUGER OTHER) p DESTRUCTION (chcase typa below) <br /> o SOIL JkORI G* �r1' It-o".9 <br /> 13 OVkFFSO17E 01.A"ETi:RE ra% t •maclt � i. S� C*tee*SURE GROUT f r5KOU T SPECIFICATION s <br /> TION Tvig C.OR+ jTROrTMHSL?EGIFt0ATIO]J.. <br /> f! <br /> ,j<,90NTT0R1NG Xnii LOW STF-M DIA OF EOREHOLP-&L d MULTIPLE CA.SIN3S n MULTI-L&VEL WELL CASING OEA; <br /> L CXTRACrION a AIR HAM MEWPPLIVEN CAWNGTH,C]KNESS EL9Z, TYPE OF CA91N0, QBTFEL XPVC 20THER <br /> I]VAPOR Q MUD ROTARY DEPTH OF GROUT S � TREWE TYPE TO®E USED O AUGERS CI HOSE <br /> QaJRSPARCPP_ OZONE 0PUSH POINT taP-CPT)4RQUTSE-AL PUMPED pYes UNo (NO'T`t. MAXIMUM FR.EF_+A_t_ DIEPTH IS 30') <br /> 0 AOJ1 BORING D HANDAUGER <3ROUTSPECIPICA71ONS <br /> 1116ThPR APPR4X �QRINt317EPTFi 20 r QB0LTE0TRAFPi or }�STO`JEPIF' <br /> i-_OtvDIJUTOR CASINO FROPOSEt3 (If YES,Ityt apwdilaati n_-In=rnment se don) <br /> COMMENTS L"eLL OJ A”, <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> d8 WORKING HOUPS NOTICE REQUIRED FOR INSPSCTIONS <br /> *ereby aartl4y that E have prapared th[a appilcutlon and that the work will be done Fn accordance with SArr Joaquin <br /> Counter OrdiSa tilos and R=guiattons,and all applicable Cailfornla St.xtir Laws <br /> S�+�nar3 � 1'114elcompHny ��r- r tcf Yt'larrar/rr (a �t �]r� Svu <br /> Print Name - rcI [d e.H _❑ate I J r4fQZ <br /> DEPARTMENT USE 0y_ <br /> SITE MAP IN UNIT IV FILE,ADDRESS- <br /> WORKPLAN DATFOI <br /> A-3�ca�on A-cOP%d <br /> 2 1 inspe0lan ay Date F,nal Inspiectcin By SIA <br /> ;pes"gorin Iiisp4cuon Ry flare <br /> C0 1M8NT$;CONDIT1ONS <br /> ACCOUn6TINGONLY A109 FACS <br /> ,I2 cob" T.F INFO AMOUNT 9FiWTTr=C1 ni A REC'6 SY DATE PERMIT r EEAV%CF REQUEST# tNVOtCSr <br /> 9/30/02 <br /> -7 WC -WATVER C-57 Letter' of Author+izatron to sign parmpt Erlcroachrnmiri dOC <br /> r <br />