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02/17/2005 13.47 2094683433 FIFTH FLOOR PAGE 03 <br /> *� San Joaquin County (� G INtL""� <br /> T-'z "76 Environmental Health De axe SITE <br /> P <br /> 304 fast Weber Avenue,3rd Floor, Stockton,CA 9S2 �,�f tGA-nON <br /> '�`K (209)468-3449 Fax (209)468-3433 Web www S3Sov:rAV; V�NIT I1/ <br /> j- Well Permit Application � WP <br /> C <br /> F-5 0 3 2095 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISS <br /> Applicat IS herot7y made iv San Joaquin Canty for a permh to Construct and/or match the work de acd �n compuanoe with San <br /> Joaquin County Dawlapmwtt nle.Chapter$1116.3 and the Standards of San Joaquin County Envmnn <br /> v+<sLL <br /> Locanon ' So Al. W- 5v+h W� �rossssbvet ✓ I`n Cay .6db p�s rs <br /> Ij <br /> PROPERTY <br /> , Adam l3llb .,,acyla� H <br /> CW F�5 5� 70 a,�one1M Sd 2921-358 j <br /> C.'I'7'Cantractor� 1� a�-e City a � Zlp`i28o�L�e819� an.$��g�s�� <br /> coresunaNt1 sub cntr elev C cclas.4 31 f rtrj `'�';`"city gS �SzL Phort4 7� 96 �3 <br />' PIF Gorxdinatas X Y TP RanVIR <br /> ' <br /> MW TQ I&MRFORIaER. <br /> Q NEW WELL! ORNW. (CPT GEOPROM HMROPUNCH HAND-AU R am *) �,,DESTRUCTION (cho "1CA-o mow) <br /> Q SOIL BORING 0 Ovi jORE DIAMiTER�1— <br /> PRESSURE GROUT <br /> GROUT SnCIF"ICAPEONS <br /> COMMENTS, <br />' TYPr OF WEiI, WGINUA111AIM211 2graTRUCTMN SPxC!n;& <br /> Jr <br /> ISJA <br /> HFTORIN13 �FiOLLOW STEM DIA.OF EORENCLI"� a MULTIPLE CASINGS 0 MULTKEVEL WILL CASING DUL <br /> fl EXTRACTION d AIR HAMMERIDRnl01 CASING TPIICKTVESS,ffL . )ea—TYPE OF CASING i1 STEm APVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUTS r '0 'PREMIE TYPE TO BE v= a AUGERS p HOSE <br /> II AIR SPARGi1 OZONE o PUSH POINT(Gp or CPT)GROUT SEAL PUMPED. Yes U No (NOTE: MAMMUM FREE-PALL DEPTH IS 301 <br /> II SOIL SORING 13 HAND AUGER GROVT SPECIF1CA71oN8_ -� 1 ---- <br />' !1 OTHRR: 0 OTHER APPROX.BORING DEPTH �0 1, D BOLTED TRAFFIC SM or I!STOVE PIPE <br /> CONDUCTOR CASINO PROPOSW (If YES.kat spmesmftm in oomntem section) <br /> �COMIIk'N75 <br />' NOTE; OFFSITE SORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS- <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTION& <br /> I hereby certify that I have pnllpan!d this application and that thg work*ill be done in aecmordenee with San Joaquin <br /> County ordinances, a"Regu a,and all applicable Calif0f0la State LffW'L <br /> Signed x /1.r c .fs ' TitielCanperly + <br /> Gs*••s I <br /> Prwt Nine j G #'- o I I Data Z^2. zap - <br />' DEPARTMENT USE ONLY <br /> SITE MAP IN UNfrIV FILE,ADDRESS: l�5v /l�- N. <br />' WORK PLAN DATED: <br /> Appix anon Aooepwd By PI-Te Issued <br /> 05 Arca° <br /> G""Inp"Mon 11 Date Final Inspection By Data <br />' Dembuclien Inspection By onto <br /> COMMENTS I CONOMNS <br />' ACCOUNTIN13 ONLY AID# FACO <br /> Ise cmes; FM INCHECKS REC'D SY RATE Peow 1 SIMICE REGIU b'T S rKV01—F <br />' C-V-K WC—)!L""WATVER C-97 Letter of Authorization to sign permit Encroachment dac <br /> z-0ot <br />