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UZIA11,WUb Lb Jtf dUJ4bUJgJ4 h-H0 PAGE 92 <br /> . . iv- <br /> San Joaquin County W E C c IfEnvironmental Health Department SITE <br /> 304 EaseweberAvenue,3rd F]oor,Schon,CA 932&a x 2006 MITIGATION <br /> • (209)46&3449 Fax:(209)468-3433'Web www- ih�'qdN�THEALTHUNIT IV <br /> Well Permit Application PERhr,ITISER'VJCES <br /> NDN-REFUNDABLE PMWIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> ApplimUon rr hereby made to San Joaquin C*UnV for a Pemul to construct endlor wz%U Go work dow bed. Ttus applimbon Is mad*in Corti003=e with San <br /> Joaquin County Dovolopntent Title,Chapter 9.11115..3=W the Standardsrof_San JoagUln County ErWa nmenlal Health Depattmont. <br /> WELL Locabon l all AlvrM l�a(")7 ross Street 1-0 t4 Ise city IYGYIle ffl— Zip 9s'33� °'ZI7 70 7^�J <br /> PRGPTT.�iQ��ir�Q 41;e TR 14 8,4, �.LeUise !'1? tGc,�r 9 -33L <br /> Orme dyes � $-PI7on ��� <br /> Cir Cowlcb JAI P8 72 rew c/so F fa we sad cL;b, QI I 4 i udE`�frstGr�r}1O1„¢(9LS ala-s�o p <br /> Consultant/SubCrrb a dross n �T Ciby lL-lJdl Phare0L707) Q3s Ta sO <br /> GIS Coord;natas-x 37•fit 155 Z_,Y .I L 10 Z t l-I)�aY,Townuhtp !r7 Range_-7 to Soedon3 2'� <br /> WOttK TO�PERFORMED- <br /> p NEW WEI L/BORING (CPT,Gt OPROBE.HYDROPUNCH,HAND-ANGER,CvrwMn )�bESTRUCTION (ehoore type bebwr) <br /> 11 SOL aOR[NO$ 13 OVEIt-80RE. DIAMETER✓, <br /> DWELL>f UrPRESSU RE GROUT <br /> 13"fir GROUT SPECIFICATIONS <br /> COMMENTS S47q[r-- oil✓! al S =5Tht t I/��i15 <br /> XES 9E NE11 INEMLLAME TYPE C-4 aMTRUCTION_SPEC1Fi4ATIOtM <br /> WAGNMORING 1]HOLLO'NSTEM DIA.OF BOREHOLE l]MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA. <br /> 0 EXTRACTION 11 AIR HAtuIMr:p/DRIVEN CASING THICKNEsB_TYPE OF CASING 0 STEEL 1]PVC p OTHER' <br /> U VAPOR 1]MUD ROTARY DEPTH OF GROUT SEAL. __ ___TREMIII TYPE TO BE USED' d AUGERS Q HOSE <br /> 0 A)R SPARGIJ OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED n Yes I]No (NOTE: MAXIMUM FREE-FALL.DEPTH IS 30') <br /> BSOIL BORING p HAND AUGER GROUT SPECIFICATIONS <br /> I]OTHER. n OTHER� APPROX.BORING DEPTH. R BOLTED TRAFFIC BOX or pSTOVEPIPE <br /> CONDUCTOR CASING PROPOSED Cd YES.lost spedNeailons In emment section)i <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby cert"that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinalnc d Regns,and all applicable California State s, <br /> S;yttod /�+�r�� TitlelCotnpe .�•T •+� M /fJ�//�� .(//'d� ` <br /> Pard He Date r� V <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE.ADDRESS: 0 �- <br /> WORK PLAN DATED: E 1$ zoo/. <br /> Appgcador,Aaocpt¢d BI► �.. Dew Issues 2-21 -OG <br /> Grout Inspection By, 09te Final Inspodwn By,. <br /> Doslruc*n Impecdon By <br /> COINMMM/CONDIMOM - <br /> r <br /> COUNTINGONLY, AIDS FACS <br /> CODES FEE INFO AMOUMTREmTPED CHECK* REC'DBY DATE PERMIT/SEIVtCE REQUEST0 INVOICE <br /> 5021*60.00 60. 00 SRIF OO�f�8$ Q <br /> C-57 WC-WAIVED„_ C-57 Letter of Authorization to sign permit Encroachment docF, <br /> • MM29 l <br />