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4-12-205 8:32AM FROVISCHDRILLING 2097723571 • <br /> FIE <br /> ��PY <br /> San.Joaquin Cou»ty <br /> � '' Environ►nentat:Health,�eparle�tt SITE <br /> 304 East Weber Avenue,3td Floor, Stockton;CA 95102 lVI1TIGATION <br /> 4 ' <br /> (209)468-3449 Fax:(209)468-3433 Web WwW.Sjgov.org/ehd UNIT Int' <br /> :-Well::Pennit Apptigat"ron <br /> NON-REFUNDABLE PERMIT EXPIRES 4 YEAR FROMZAT'E ISSW'•6D <br /> Application is herehy made ld San Joaquin County for a.permit to cons uct andlor'install thework descrioed. This.appitcation is made In.complianoewith San <br /> Joaquin County.Davelopment Title,Chapter 8-1115.3 and the Standards of San Joaquin;Cour¢g Environroamal Health Department. <br /> Owner <br /> . rt5pAd2a� uzra <br /> WELLLogationIRDyW - Chctr}Cr & CroesStreet caILOZOO- <br /> PROPSg,TY <br /> 6gdCy h <br /> 1 CIILT(7�CIfkddress31PQ kaiA�50U1 NO- City4Q'4,01.(L F& 6Yip„��_Pnona# <br /> C.57Contractor it56 y £.CtVECb�Addr¢as3 )WA 683 l <br /> �� sherrts VJace. �c scr�zipg57�-ucu <br /> Consultant fSup.Ontr�CUlgd}I�I ,,,i�CCril'3,Addresa NL•I IYlo1l1.S1T.2IJ�" CKy�(15n0 Lic*� .PhonegfM5 2.U.4-25-35 <br /> GIS Coordinates'X-_,Y Township Range Section <br /> WORK TO§k PFRFQWED; <br /> )CNEW WELL I BO WING (CPT.GEOPRQK,HYDROPUNCH,)4ANQ-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> )LSOIL BORING# q OVER-BORE. DIAMETER <br /> dWELL#,— _ --- SS O'PRESSURE GROUT <br /> GROUTSPECiOCATIONS <br /> COMMENTS:-- <br /> TYPE OF <br /> OMMENTS:-7YPE.OP WELL INSTALLATION TYPE CONSTRUCTION SP CIF,ElCATIONS, <br /> a MONITORING (}HOLLOW STEN} DIA,OF 80REHOLE B MULTIPLE;.0 IN 8 O MULTf LEVEL. WELL CASING DIA: <br /> U.ECTRACTION Q AIR HAMMERIDRIVEN CASING TwcoESS TYPE OF CASING: p STEEL U PVC p OTHER: <br /> a VAPOR U MUD ROTARY DEPTH;OF GROUT SEAL TREMIE TYPE TO 9E USED: GAUGERS TIHOSE <br /> Q AIR SPARGE!OZONE; PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a yes: v No.(NOTE',:MA)UM.UM FREE-FALL DEPTH IS.301) <br /> •($OIL BORING 0 HAND AUGER. GROUT SPECIFICATIONS l "k'DFlt'}'Qa <br /> Q OTHER'---�,-_,..�.�6 OTHER�,,;,�,; .APPROX.60RINC DEPTH ' [)BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED of`IES,list ape fixations in comment,section) <br /> COMMENTS Soil Donn y }a k ia5tztiltd u 'tU 5'' bhb It5iJ1VA ,QtfPG-}" ous.h (TiC�-dT� '•. Pinl'ipq�ytiill bf, <br /> NOTE: OFFSITE SO.RINGSaREQUIRE ACCESS=AGREEMENT OR ENCROACHMENT PERMITS. <br /> 46 WORKING HOURS:NOTICEAEOUIRP'IFOR INSPECTIONS:.. . .' . <br /> I hereby pertrTy.that have prepared this applicat on and that the work wail;be done_in acogrTlance with San Joaquin <br /> County Ordina Ru es aitd e I r>,:'and ail applicable Calftirita State Laws. <br /> Signed z_ SS-- pyy'� `` This Company <br /> Print Name leil \7 9a tl== ! Date It O <br /> DEPQARTMENT USE OI4 Y_ <br /> SITE,MAA 1N UNIT IV FILE,ADDRESS: — <br /> WORK PLAN FATED: 7-12 O Z jjs M,«� A22 441=4�= —C <br /> Application Accepted By .,, Date Issued '-g'ZI_b S Area 66 / <br /> Grout Inspection 13y_,-- —Dote Final inspaWoo By Date <br /> Destruction Inspection By Date <br /> . .COMMENTS I-GOHWTIONS: . .. . <br /> ACCOUNTING ONLY; AID# <br /> FAC#. <br /> PE CODES .PEE IN WOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# IN.VQlcr <br /> 1 yah 1 Fq- oo�lt�15 3-Is sR# DO lnl2 <br /> C-57T WC_ WAIVER__ C-57 Eett¢r of AuthorizDtion tmsign•Pertnit ✓Eocroaahment dqc <br /> FV0,119-02-001 <br />