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F'FTH FLOOR P�SGE 02 . <br /> r ;} / WELL PERMIT APPLICATION FORM SITE <br /> u L SITE <br /> MiTIG i! <br /> SAN JOAQUIN COUNTY UNIT IV <br /> MAR 10 2004 ENVIRONMENTAL. HEALTH DEPARTMENT (EHD) <br /> ENI`lRi�fdll Lf;} s!� la 304 E.Weber, Third Floor, Stacktosl, CA., 952 i <br /> PERMIT/SERVICEcT� (zo9) 463-3 449 <br /> N .REFN]NpaBLE FEFi1fIII EXPiR99 1 YEAR CIM DATE ISSUE^u <br /> ii <br /> clistruct de 11 to cI <br /> Application is hereby madeoco Tit'Joaap'a 9 111�f3rand permit <br /> he tandan9s o 5anf 7gaqui>wounty EnvirCmmeniall He t i D parErnen dde in camp4ianc4 with an <br /> �oaquif+County 6ev9 t I Ass05s4r's6 11 1;0 I� <br /> Parcell <br /> WELL Location 85 (rut Gro++a R a Crass S stet 1 i eh� e C1iy^Trcr�torL_ P � s <br /> Ci-c1p I it crncicFon " _Zip_ 9 21� Phone# 209-951-1^ it <br /> reoratiarr Addrer,6 6265 Croake S -- <br /> PnOPERTY Owner BE Q-—�— <br /> Isl on_ _Z'sp 958a Lim G57 72 �Od phoned 916:??-NiC <br /> 0-57 Con[rnttar V&W prilli E Address, P.O 60 410City„^ — I Lle#__— <br /> phalle# 2 <br /> Es aIo <br /> Consultarltl Sub Contractor,.Graura Zer sia Ina Address t Main 6t eat Csty n <br /> BE Section 4�� I <br /> Y y5S•N ,Township 4NRen9e- � <br /> GIS Ooordinates:X 26 II <br /> 3O 6E pER€ORMTRUCTION(choose typo be <br /> OESlow] <br /> (}NEW WELL 190R1NG(CPT,GFOFRCSE,Hyl )ROPUNGH,HANp-AUGER,QTHER' ix3 [X]OVEFc-t50RE(MWi,MM) <br /> p Sc1'_BORIS G;9 vq PRESSURE GPOET(Cthers) <br /> Q WELLS firoutSFecin tions: Neal rren treeni d then re <br /> *Other._ I II <br /> COMNJENTS: - <br /> TYPE WELL !TSTA LATIOII Y1i PE NS T Rt3CT10N SP ICA7lONS <br /> N NE__CASING DIP.:`^ <br /> yOLLOW S T F-M DIA-OF BOREHOI�;.�._-MULTIPLE CASINGS?Q YES p 0 I) <br /> pq idlONITORNNra 11 TYPE Or CASING: a STEEL j]FVC Q CTHE�- <br /> 1g EX-fRACTION V AIR HAMM!` DRIVEN D s�THICKNESS <br /> OF SF-A�- TRFMtE TYPETO 8E USED: GAUGERS p HDSEI <br /> Q VAPOR Q AnUfr ROTARY <br /> RUSH POINT <br /> 6 GROUT SEAL pUMPE7' [I Yes a Na (NOTE: MAKIMUM FREE-FALL.DEPTH 15 30'u <br /> AIR SPARGE PECIFICATIGNS t3 <br /> [�SOIL BORING Q H?,M1D AUGER GROUT S � 0LT1v0 TRAFFIC BOX or Q STG1r�PIPE <br /> APPROX.BODING DEPTH I <br /> Q OTHER_ - CONDUCTOR CASING PROpOSEI r —(if Y53,fist spedficatic,�s here): <br /> dTwE .-II <br /> 'COIVIIVIENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE <br /> Ou sCESStN aoltOAN E�FO�tOACHNIENA QU RED NSP ECIvII TIONS, !� <br /> CALL THE UNIT IV IN <br /> ALL F? <br /> SPECTt}R+tB WORKING H <br /> orad this application and that the WOJk will be done irk aGcordant:e with Sart Joaquin i� <br /> s <br /> I hereby certify that I have prep la applicable California State Laves. I� <br /> county ordinances,Rules and Regulations,and all app <br /> I��, _ _Q _ TitltlCompi IY C <br /> Signed x `f•��_� _ DafiB�t .d�..� .s o7 nsZero Ana• - ttc, <br /> eI� <br /> I� <br /> Print Narm ohn P. DEPAI IIA NT USE(ONLY !1 <br /> I. <br /> it <br /> SITE MAP IN UNIT 1V FILE,ADDRESS: I jl <br /> WORK PLAN DATED: <br /> j ! -Area `T �• ' <br /> Date 15$U16 r <br /> D25e�-•I. <br /> Appllration Accepted By Date �FI Iai Inspeaon By <br /> Grout lnspec0n 6y pate li <br /> Destructivrt Ina eo6on sy <br /> COM <br /> MENTS 1 CONDITION& 11 <br /> ACCOUNTING ONLY' AID# <br /> ?6 CpnEs FEE INFO AMOUNT R MMEO , CHECK# RgC'I]uY ' QATE. PERMIT t SERVICE RE4LIEST t INVOICE j <br /> -� p' / .? <br /> 1I251C <br /> C-557,.,..-,., WC _WAFV€R_ C-57 Letter of Auihorizotion to 51gn permit—Encroachment doc_ I <br /> it <br />