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6& P iLE COPY16-�Al <br /> QUIN COUNTY <br /> ENVIRONMENTAL HEALTI i DEPARTMENT <br /> uq,F,, lTwanQN <br /> F <br /> AJC 600 Fast Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3454 R <br /> ax. (209) 468-3433 [41ob: www.sj.qov_cd­9Lehd <br /> WELL & BORING PERMIT APPLICATION 9 <br /> FOR VVELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIM)* <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Application is ,rltwssrsade.to San.1onquar Count`/ R <br /> for a Denit to construct and/or Ne desUined. This made in ,';i 1 <br /> le11 <br /> Joaquin County Dcvelopaiew Title,Goarpter 9-1115.3.and One Standards of the Sin JoaCUin County Environmental Health Depannient, <br /> Site LOCatis]r#�Wfo SIr,,,l :' e ("Ily ;�Zlcy 71P.— Aj-NZD?ZZ_00(6, <br /> Property. Ceofoseoaws <br /> Owner R442AAI_gfi0FI Address It <br /> C-57 Contractoq!: jW- 734!IF,41 Ad2d4ress <br /> 365, <br /> 2 <br /> Consultant/Sub Cn1s4rAA_ Address � <br /> sty '0W_ WLIL <br /> P h on a <br /> Billable Pady-- 4o" Address City Zp Phnne <br /> GIB Coordinates:X_ 1y— -6/0 T <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING ICPr,(ILOPRQPF,E�DROIF�UNCII,HAND AUGtH.0114ER) <br /> SOILBWBOR <br /> IN IDS bs-7V--*,,0 <br /> —V <br /> VVELT IDs_ <br /> OTHERsTYPE&fMOFWEIN INSTALLATION TYPE CONSTRUCTION SPEC11FICATIONS \J\ <br /> 5)CNsOrjsrORiNc *_�OLL""'TEsd niA OF BOREHOLE 6"r/V'rjkTTT[PUE CASINS 5 LI MULTI L EVEL FIE LL CPS;r4G CIA <br /> 0 EXTRACTION Vapor/Water Ej HAI IM, Pr)RUFN :AsINR-,HICKNESS If FjS7rIFI "K-IC [I ETHER <br /> 3y'SOTI.VAPOR,W�Vmll C]Ink OTARY C.FPTI I C)F(�I`Dj I:;EA -1 RF,NIIE TYPE TO BE 0SFD Al.sGERS HOSE PIPI <br /> "�Soll.BORINC 11 FONT GPI CPT) GROUT�i[­A[ PIAIrED x Yo., FjI )(MXIIAU x <br /> _kFRrF-AI I DFPTI1 SW F 1) <br /> INJFrn(7,N,, 0— <br /> (:RODT SPI ICA I IONS Tt opmAti b <br /> EIC)THER — APPROX SORINSrEPTH <br /> ;1 116' r 5OLTEO TRAFFIC BOX OR'UKIOVL PIPE <br /> s7 <br /> CONDUCTOR ASINBXN'n Cl m5 Dim _C,,,'ng D,,els S.r.'g Dim <br /> COMMENTS ------- <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED DESTRUCTION METHOD'(CHECK ALL 'HAI APPLY) <br /> 406"WELI(S)TOBE D-STROYED [I OVER-BORE DIAMETER OF TI <br /> VW-1 I I Ds, E;PRFSSUREGRCUTTO0FPT1I0[ IFF P11OVISURFAn; <br /> GROUT SPECIFICATIONS U EXPLOSIVES FROU_H) FT SHOW S%,1RI ACE <br /> TREMIE TYPE 10 BE USED:El AUGERS []I i0SI, E PIPE L]MUSHROOM CAP AT(>3' )_FT RE,0,SURI Act, <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations.an5"pticalare California laws. <br /> Signed Thle,`Cuonpany <br /> Print!dame ----- -- Las? <br /> DEPARTMENT USE ONLY '/ <br /> a <br /> SITE MAP IN UNIT IV '11 F SITE ADDRESS <br /> WORK PLAN DAI ED <br /> APPLICAI ION ACCEPTED BY _45k - DATE <br /> GRUUIINSPICHONBY FINAL INSPECTION BY UAIL <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCUUPI IIP( ONLY Il <br /> sL�Evlcl- Pots II <br /> I,F _'(A)FZ I r F INFO 'dT REMITTED (.HECK;V� V'D BY )AII TRIOICL <br /> 0 (11 It �,I 11, <br /> qT6, REC, I <br /> j 16103 31+ti '36b 'jq6q <br /> 2-2- <br /> 41114 <br /> FILE COPY <br />