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02/17/2005 13 47 2094683433 FIFTH FLOOR PAGE 02 <br /> San Joaquin County <br /> ORIGI ' A' <br /> N�MEnvironmental Health Department 1TE <br /> Y7 y <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95242GATION <br /> (209)468-3449 Fax (209)468-3433 Web www sj90v ar4§0 ;' EMNIT IV <br /> C���p ✓ Well' Permit A Application Pp n it 7045 <br /> NON-RL"NDABLE PERMrr EMPIRES 1 YE3 M FROM DATE ISSUen <br /> Applloation is hereby made to San joaquut County for a permit to construct and/or install the wn*describ �l� mAtianoe with San <br /> ' Jaaqurn County 0eve+wment Tr" Chapter 9-1115.3 and the Standards of San Joaqum County Enwon <br /> WELL Location �rj© Al Wl(5005 WA cross street 1 T+++ lire tctty 5�-oc 4b�Zlp `� 2N Paro . Q <br /> POwnerffi� 0ddress 13�16�� � c,ty_5 + f r'Z1p F ,nye 6 z 5 sy! 3 s0 <br /> ' C37 Carrtrador1k)r15�^Nt,Z -AUf_)Iin Address 1016 X In_A__city I f1l'1,9A01a XpL2—8 —i_u c*1d a& ono#71 <br /> Cortsuittarrt l Sup C=_edjH,d+�►W e C+�s.l `4ddress 3lS!►},rw c y 6 6fs 2te15,w;iL!r z-4 phane*_a±2 b b N <br /> GIS Coordinates X _ Y_ T.hrpp 5� R3ngra tie '3 Section <br /> WORK 1!2 13E_PLBL(2fiWvy, <br /> tNEW WELL I BORING (CPT,GEOPROBE HYDROPUNCH RAND AUGER,OTHiEW) q DESTRUCTION (chume type betaw) <br /> p SOIL BORINGiA � Q OVER-BORE BORE DIAMETER <br /> SWELLS 'OL a PMSSURE GROUT <br /> p"Other GROUT SPECIFICATIONS <br />' COMMENTS; <br /> TYPE OIr�IFyLL CONSMUCTM SP41CM- AT90NS �7 tr <br /> MptuRORtnt3HOLLOW STEM DA.OF EOr�EtiOLE�» Q MUL-APLE CASINGS Q MIAT1-LEVEL WELL CASiI+tG fltA. <br /> a eXTRACTION Q AER HAIR MERMRIVEAI CASING THICKNESS:ac J_ YO TYPS OF CASING 0$TEFL WVC 13 OTs`M <br />' ` A '1'! <br /> VAPOR I7 MUD ROTARY OATH OF GROUT SBAL - - 1 TREPML-7 fM TO SE USED: 'AUGERS a HOSE <br /> rp AIR SPARGFI OZONE 0 PUSH POINT(GI'or CPT)GW)IJT SISAL PUMPED Q rtes Q No (NOTE: MAYJMUYI FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER gROUT SPECIRCATIOfVS�„_ <br /> 14VOT!-1E rf OTHER ROX BORING De-Ttt r TEDTRAFFIC sQX or Q STOVE PIPI” <br /> t CONDUCTOR CAwNG PRcPCSeD&to (if YES,Irat specHiaalorts in 00mmew section) <br /> COMMENTS +� <br />' NOTE: OFFSITE SORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby oorOV that I have prepamd this applleadon and that the work will be done in acanrdance with San Joaquin <br /> County Ordinances,%Ru and Regula)"n ,and ail applicable Cx ftmita State Larva. <br /> Srprted x�, Tate/Companyr � f'LP/ +,.L <br />' Print Name ►�+G�`t-�d Date� 7,-Z—6:SQ�� _ -- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADOR!<SS: Grp <br /> WORK PLAN DATED' <br /> App%=wxn Accepted By Date lswed <br />' Grout Inspection ay date Final Inspaeenn By bade <br /> Owirucuon Im =n BY Date <br /> Ca1MMEN7'B 1 COHO1T30h19 <br />' ACCOUNTING ONLY AIDM ICAC# <br /> tali CODES FEE INFO AMOUNT R>•wnwD CHECK# FREUD BY DATE PERMIT f SERVICE rlwuva r-P INVOICE <br /> SRO <br /> C-57 W4q / WArVLR_ C-57 Letter of Mthorizatian to sign permit Encroachtnent do- N <br /> ia <br /> EHD2S6r2VO4 aa-ooz <br />' 6rnro� <br />