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1.1+000 P.I <br /> Apf . 6. 2007 1 :21RA Wr Env i ronfrenta 1 5152 No- 8865 <br /> LI) <br /> FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> . .. . .. ENVIRONMENTAL HEALTH DEPARTMENT(EHD) <br /> 364 E.Weber, Third Floor, Stockton, CA.. 95202 UNIT IV <br /> (209)468.3"9 <br /> NON,RIEFgmRM"PMWEXP&RES I YEM FROM OA ISSUED <br /> Application is tiers"merle to San Joaquin County for a pammll to canstrud andlor In.mij the vAA described. TNG application Is made In cornplatum with San <br /> JWuln Courtly oew1opnrentTede,chapter G-1115.3 aM dw Standards of Son Joaquin County Environtnanial Health Deparim,ant. <br /> Asuma� <br /> WELILLocallion ft <br /> PROPEM Ccs COK3 13 <br /> 0,;mr C&_kE - SAG _T' s <br /> C47 Contmelm N Addreatt. City Zfp_Lk#_Phwek_ <br /> wr 95r4v, oJMFAIT09-- <br /> camumard/Sub Cntr-j5EgJL <br /> -C�C. Addm"Z31-5'j5, <br /> GIB Coordreites:0v%3f ftl 4n%�-124- (.7 . Tomahip Range Section <br /> WORK TO <br /> ,tNEIN WELL/BORING (CPT,GEOPROSE.HYDRO PUNCH,14ANID.AUGER,OTHEW) (IDESTRUCTION (cn0000typabelow) <br /> Q SOIL BORING# 11 OVER-BORE. DIAMETER <br /> WELL N 0 PRESSURE GROUT <br /> �AhFPW- PK086. GROUT SPECIFICATIONS <br /> NT3:­­­­ <br /> §P-ECIFICAlmom-S %AWP*L PLAj A)Ub _COD fi?M4VLL> <br /> TYPE OF WELL INUALI'A�TYPE Commit 3^a MULTIPLE CASINGS 0 MULTI­LEVIEL WELL CASING DIA: <br /> 1]MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE.1- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN GAS ING THICKNESS TYPE OF CASING! RSTFEL I]PVC ,QTHER:-icFizlA/ <br /> >(VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_TREMIE TYPE TO BE USED: Q AUGERS C HOSE <br /> I)AURSIPARGFIOZONE 0 PUSH POINT(GP or CPT)OROUT SEAL PLIMPIED. 13 Yes C No IIpREE-4FALL DEPTH IS 30') <br /> [I 501L BORING XHAND AUGER rFtouTSPEC1F?CATPOPJS_ 0-P 7-2l <br /> 1]OTHER- OTHER_ APPFtOXBORING DEPTI­t-,5'�-0f' J]DOLTEDTRAFFIC BOX ev USTOVE PIPE <br /> CONDUCTOR CASING PRPPO�SED (if YES.Ila 5 111 Unna in <br /> COMMENTS- ti <br /> —A 4</� z4w&i4�""Le~ <br /> A <br /> NOTE: OFFSITE BO REQUIREACCESS AGREEMENT ENCROACHMENT PERMffS. IE <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS- <br /> I hereby calartIfy dot I have prepared this application and that the work will be dens,In accordance with Son Joaquin <br /> County OnRivaness,R I lations,slid all applicable California State Laws. <br /> Sipadx Title/Cmpany <br /> --Date—`! &/o-7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1 1 V FILE,LE,ADDRESS:—— LOP- tzy�-b '35.z <br /> WORK PLAN DATED! <br /> AppikollonAocaptao By _Dela ft;suaq <br /> Grew k"moson.By to91( g(M-r-Fivelln5pecdonffy <br /> I <br /> Oftirvotion Irspactlon By Oats <br /> COMMENTS ICONDMONai <br /> ACCOUNTING ONLY: AIDIII FAC# <br /> PECOIDES FFFINFO AMOUNT REMFTTEO CHECK411 REC'111 BY DATE PERMIT/SERVICE REOUEBT 0 INVOICE <br /> 350, 16,5 ung- iaf7, iLu S RO 019507-1� <br /> C-57WC WAIVER, C-57 Letter of Authorization to Sign pel"IT1111'M Encroachnirmtdot-d4 - 9/30/02 <br /> /k b "L'e� veal <br /> le, <br />