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L7/2008 14:40 5102374574 PRECISION SAMPLING PAGE 02/02 <br /> 10: -12 2094GO30 EHLI R Gt 02 <br /> yr <br /> San Joaquin C( anty <br /> Z Environmental Health Department SITE <br /> 600 East Nlain Street, StOOICEOr A 95202-3029 FF <br /> -9 14 2e ITICyATION <br /> (209)468-3449 Fax: (209)468-3433 b:w. v.sjgav,org/ehd <br /> Ei,MR()MME.TdT Nti�'� IT IV <br /> +Fa Well Permit Applil ationgpnIT'S • <br /> NON-REFUNDABLE PERMIT EXPIRES I Y1 NR FROM DATE ISSUED <br /> APPI atlon Is hereby made to San Joaquin County fora permit Io construct and/or ,etall the wo Environmental his Flaanh IDetladmaMon is ade In compOnca will San <br /> Joaquin Ccnanly i]avnylo^pmeCntrT,iltle,ChaptAr A-I Ii s.3 and the Sinndnlds of Sant quln eounb P Assasaors <br /> WF,LL LOOT,AvIIOn�✓T Fi-11 M1��N� Croaa Street & city ziPQ�aaZ' ParcoutyQ 4'QL <br /> PROPF V1 p .. 6 c.. q"t,�' p <br /> YPhonelf -11} `- Li'1 11,075DQwn;rZ Surd::... L 1� : '}}, I¢.d N%' '�. . <br /> c-s1/contractorl�rrcial prvcXl'I'f1'iJAC rb n 105-1 SSe city�yy Clpgi �-L¢ Pnona#Slo-A+ 45-+S <br /> app P <br /> Ceneultl,ntl IIub carr��S _Address �a� QitYoalc.Icwd.LiGt Pnonn#.ISIC•3tD"QUI-�I <br /> 013 Coordh,atas:X�� � •Y t� • r Township •N Ran4e �' Somion e�0 <br /> WORK TO BE PERFORMED: Cp <br /> 0 NEW WELL!60RINCa OFOPROBE,HYDROPUNCH,HAND-A ER, mr <br /> oCTHE ) a DESTRUCTION (dhonse typA aglow) <br /> 0 OVER-BORE. OIAMETER _ <br /> PRESSURE GROUT <br /> U WELL# >M• FL`L. 3 YY1 •- 0 /.(�� <br /> p'Ctnar M. .rn�r��?��L -�G' U✓L�� �'� IL 11J OROVf SPECIFICATIONS <br /> COMMENTS: !y�_LY1.�4'L UV1�1��,41^ -LLEYYI 4?th YYY P. G.�L G�I��C.,, 3CPa� <br /> pET'-1 OF WELL TAI . A9 TYPE ,CaQUS RUC I N SPECICA ^J` <br /> MONITORING 0HOLLOWSTEM OIA.OFSOREHOL - O MULTIPLE CASINGS 0MULTI-LEVEL WELL CASING DIA:=y- <br /> O <br /> U EXTPACTION n AIR HAMMER/DRIVEN CASING THICKNEB6 TYPE OFCASING: 0 aTEEL 0 PVO O OTHER: I <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEP PC TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0AIR SPARGE/OZONE 11 PUSH POINT(GPorCPT)OROUTSEAL PUMPED 0 -s ONo (NOTE: MAXIMUM FREE-FALL DEPTH is 30 <br /> 0 SOIL BORING p HAND AUGER GROUT SPECIFICAYIO S C �GbR.1.)'tD1�1' ,.-.. <br /> APPROX.BORING DE '�`a0/ 0 BOLTED TRAFFIC BOX or D STOVE PIPE <br /> `y(J QTHER: THER,._I�I P <br /> t `N CONDUCTOR CASING ROPOSEP (If YES,list spec cations in commentsecHnn) <br /> COMMENTS: <br /> NOTE: OFFSITE BORING$ REQUIRE ACCESS GREEMENT OR ENCROACHMENT PERMITS- <br /> 48 WORKING HOURS NOTICE R QUIRED FOR INSPECTIONS, <br /> I hereby certify that I have prepared this application and that he work will be done in accordance with San Joaquin <br /> County and Regulations,and all applicabl lifornias to Laws. <br /> Signed x /Comparry �vi.C'Liv, �rQr�O—l•<+�5'— <br /> Pent Name OntR- f <br /> DEPARTMEN USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: H 3 E- �ti1 I ey <br /> WORK PLAN DATED: 5 <br /> Appilratlon Accepted By <br /> Data Issued `!2 « d Are <br /> 3 0 / Z <br /> Grout inspection By Date Final Inspection Sy • DaSa-3 O 0 <br /> Dentruotien Inspection By Oate <br /> COMMENTS I CONDITIONS: _...... _ <br /> ACCOUNTING ONLY: FAI FA #PE CODER FEE INFOUNTREMITTED CHECI(# R 'DBY DAYS PERMIT!SERVICE REQUEST# INVOICE� � (�Jdg SRtf 53�{oc{_... _ <br /> C-57— WC=WAIVER, C-57 Letter of Authoriza an to sign permit_ Encroachment doc_ <br /> LHO 29.02.001 WEB <br /> 9/11/2007 <br />