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nST:'•f1f. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> SW East Main Street,Stockton,CA 95202-3029 MITIGATION <br /> Telspborfe:(409)466-3454 Fax:(209)46&3433 Web:www.siciDv.org/Bhd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APP6ration is herby made M San Joaglfm CaoKy for a Persil to consbrrltaTKUor irw d the work described. This application is made In co pl'®+Ol Wth San <br /> Joa9uel Courtly Developmeol Title,d,apier 9-1115.3 and the Standards of San Jo9WIn CourdY Emrion eMW Heahh Department. <br /> Assessa/s , <br /> wenLourtion ZY03 Lacy,fEz4c oeaShael Cky jr9AFw'rB Zip Paroal# 9Y-/sn-Cr2_ <br /> Pre ; SSS SEitowe' r J cay CaAv 7USv=Zp Phxe <br /> Owner AS.flBf/ �B6b7APJ'7�'�Address —�3DTibT28z9 <br /> CST Conb= r 4Sdi7 CaaerY Rd '?i% � d.. Zip Q!!q- Lint 283326 Phone <br /> Consuhinf Sub Cntr BB+.T Brea lcQ Addres TN1PSIE �M6sR� rC� ,sAl f~,Iq1cs PW,L707)a37-/,L7](e <br /> GIs COOrdirows.X .Y ,Towrehip Range 00 Section ZS <br /> w��NRK To eE PERFORr�o: <br /> / YVELLIaDRING fCPT.GEOPR08E RYDROPt1tdCN.NIINDJNGQ2,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> [�SOIL BORINGa /Ci OVEROVER-BORE DIAMETER <br /> O WELL# sslfRE GROUT <br /> „OTHER GROUT SPECIFICATIONS <br /> O EXPLOSIVES DETONATING CARD / rt--- <br /> COMMENTS: I o 5,,j U 503 fel 1 SU Lur(� �!✓�l--t f'FN�I Ei�)T `� ���" i <br /> TYPEOFwELL IN31Arr ATTONTYPE CONSTRIv'T1ONSPECIFlCAnONS <br /> MONITORING ❑NOa STEM DIA OF aORe2, __ O WL'nP ECASINW O MULTI-LEVEL WELL "NG UU:_ <br /> ❑EXTRACTION O AIR MWERIIRRMEN CASING THICKNESS TYPE OF CASWG:O STEEL OPVC O OTHER <br /> O VAPOR O MUD ROTARY DEPTH OF GROUT SEM. TREhaETYPETo BE USED O AUGERS O HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:[3Yds O No(NOTE:IN1)UNIUM FREE-FALL DEPTH IS 30) <br /> 12SOILDORING [3 HAND ANGER GROUT SPECIFICATIONS �CJi^7�'LC,"'�� '�(,,,..•��— <br /> OOTHER, 0OTHER APPROX BORING DEPTH ZO ODOLTEDTRAFRC OR OSTOVEPIPE <br /> DCfIDUCTOR GSINO PROPOS® @YD•M�i�betu Nol,mmaa ncYon) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 VYORIt1NNB HOURS NOTICE REQUIRED FOR INSPECTIONS - <br /> I hereby cerwy that 1 have prepared thfe a Pllea(km erp am the work WE he doos I aocw" wrath San Joaquin County Onilln mss.Rules and <br /> ftegulatiolw n It apprr+bla Card owa. �- <br /> Sign <br /> Ti1leiCo,rlparry Project Manager <br /> Name <br /> K=meth B. Cook Dale. <br /> 4/30/10 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2.`­1 O 3 fn7 "I T iS r <br /> WORK PLAN DATED' 5 13 I I'Ot <br /> APPLICATION ACCEPTED BY DATE ISSAREA <br /> CUED S 3 <br /> GROUT INSPECTION sr <br /> � (M.( !i(/ti FMW-INSF'ECTK3Niln_n DATE 5 S /C/ <br /> DESTRUCTION INSPECTION By DAT: <br /> COANFNISICONDn1ONS: <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODES FEE INFO <br /> Lgol # `69•oc REC �fy ATF 4Ht1f5EVICE# INVOICE <br /> riV/o SR# 5 <br /> CST WC 1apIl11FR C57l.ETfETi OF AUTHOR2ATONTOSIGNPERMIT ENCROACHMENT DOC <br /> • HELL PERMIT APP <br /> EHD20-M 1WSW <br />