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r OF- <br /> SAN <br /> JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1888 East Hazelton Avenue,Stockton,CA 952056232 SITE MITIGATION <br /> ip Telephone:(209)468,W4 Fax(209)468-3433 Web:W W W.e1QOV.0mletid UNIT IV <br /> WELL& BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIMEIREn I YEAR FROM DATEIc UFn <br /> Application is hereby made to San Joaquin County for a Permit to constnM and/or Instal the work described. Th-B application la made in compliance with San <br /> Joaquin County Dauelopnant Tula,Chaptx 0-1115,3,and the S+aMerds of the San Joaquin County Emimnm0n al Health Department. <br /> Sim lsP.Ban_3.Zr1(7W GraYslllnl Rc aseaN S i.annwhe rs RA c�—" _2!rIP953a4 APN CJ_o(o <br /> Pow wr �.P S("7� (++hdC SAL( Address 90A L-a.(CL OrivY, City SSA 2iv 9 Z7 Phone <br /> csrcoMTlrcor h+ in Address 16,41 LtitjlA4 bG r,vt ctya^wrd Lc'-uS%4-plunag2.5.3H9^63?0 <br /> Conaurort#SubC r t Address.2 Mr,15KZ50 CkY I�r�v�1�'✓t�f�� LU Pham 94A ?27-LlY66I/ <br /> BBlable Part' r AaAw '� A&P,f g�2!50 CRY—fix'—ZIR9261R' Phoneg4B <br /> GIs c000rrmneatm.:lX11 Y <br /> LY r�eW Ir�LL$8R1 CPr EO�BE�RB�EQ: HFIPN6AUGER,OIHE� <br /> SOII BGIDi- Y�- <br /> ❑VJELLIDs <br /> ❑OTHER IDs <br /> TYPE 6a OF1NELLIBORIHG INSTALL377pN TYPE CONSTRUGT!ON gPEC(!Fl1CATONS <br /> _LI MQYR02N0 ❑HOLLOW SEEM OVL OF gORENOLE�zl❑MUI-1'IPtE CASMOS MULTI-LEyEL y,ELL GpgNG txk,RA <br /> _L]FJLTRACTION:Vgnd WNR ❑HAMNcR/ORNEN CASt1G 7WCINE55 _TYPE OF CJSWO:❑STEEL O PVC O OTHER_ <br /> _�J,]y601L VPPDR PROBE ❑MUO ROTNiY DEFTH OF GROAT SERI Ci - Ft'TREMIETYPE TO BE USED:OAWERSOMSEOPIPE <br /> ytD S01L BORNG 6YPUSF1 PoIM tDPJCFTJ b7tWTSEAt PUMPED:❑Yas,[I+fNo(MAIafI�MVM FREE FALL DEPiH IS 30 Fi7 <br /> _OMJEGTIDH n.wm.�o..-,p Hpla)AR GROUT SPECIFICATIONS MQ.d�'t tYM(f1'1" <br /> _OOTHER ❑OTHER APPROX.BORWO DEPTHO WLTEOTRAFFIC BOX OR 0STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING SrNa[3 y.:c,&V Dk:__C",Oe,,:_and,D.— <br /> NOTE: OFFSITE WELLS 3 BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: AESTMLIC'RON NETHOD:lCHFexALLT eTAP h <br /> _kOF V.ELL(s)TDeE EETRpyE�p COVER-BOREDW.7E,TE_R OF <br /> WELL IOa: ❑PRESSURE GROUT rO ov+fHOF J� SiD pE"POMWRFACE <br /> GROl1T SPECIFlCATONS ❑EXi+LOBNES FROM TO FT Savvy SURFACE <br /> TREMIE TYPE TD BE USED: ANGERS H PIPE ❑MUSHROOM GAP AT L3 FT) FTEELOWSURFACE <br /> COaM1EHTS <br /> 5 WORKWG DAYS NOTICE REQUIREb(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> Ihanby artNy tRatlM p this eppliatlon antlthatiha work wit ba dons In eccomknca with San Joaquin CountyONlnancea,Flutes and <br /> RapuNBana,and LLI a/pJ/d11 Kgmla Lavnj <br /> SbreO t / Titlarcomparo iN-SLt'0 WTT fig It.ANi'rcT.L <br /> Pnnt Noma I zea} u D Date y7Z z <br /> 7 D MENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 32. T``6 (�) PAK)id* {,',4i._ <br /> WORK PLAN DATED 4((1, 3 20(3.. . <br /> APPLICATION ACCEPTED BY _ .r 0 a N Nl DATEISSUED -1 AREA /(s9q <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> --�r- <br /> DESTRUCTION INSPECTION BY DATE <br /> COKVMNMCONDfRONS: <br /> ACCOUNTING ONLY: AID# FACa <br /> PE CODES FEEINFO AMT REMITTED CHECK# REMID BY DATE SERVICE RQa INVOICE <br /> �01 C REQUEST PRk <br /> v a125x 1 SRN Oo2 <br /> ROk 7 <br /> MOO <br /> PR k <br /> F57 / 1"!c fi WANER�-1 ra G57 LETTER OFAUTHE)FUT0N TOSIGNPERMIT ENCROACHMENT OOC <br />