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CIA `Pl,' I VIP-,P-,- <br /> SAN JOAQUIN COUNTY 2 2008 <br /> ENVIRONMENTAL HEALTH DEPARTMENT EPJ,�IR�Id,'tf�f l <br /> 600 East Main Street,Stlx*ton,CA 95202-3029 T10N <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web: I 1�$FRI IT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby osis to San Jm#M Couhty ibr a psnrdt w corsbuct wWVcr Irhatd the work Assrabd. lids appiuhlon is mads <br /> Jow*M County Develop—t Title,chapter Ii-11152 and t o Standards of SW Josq Cc"Erntorrne M I Ism OeparhMnL off^ <br /> W,N T Street CAy _Zip <br /> pct_Vk� u �'Address as�601,S1nfC,� (er.l�-et� City U-l2t�r�Dr��q,4sb`t Phos» lCQS—Di--N-0 <br /> c-w c &.w. Address q� i7n t Ll+�V.� c>ty Y Lk:s�Jj-Phone CQ-31?%-!-i ko') <br /> Com WIwntlsub Cntr (� Address LCS�h�l SSU A�u61�Q Z�CtDy S 0 MD MCA, Lk:s Phons <br /> GIS Cmmllnabs.x 'y Township Rarge Sedon <br /> ro Be PtFat�oloeEv: <br /> NOV wat LnolsNo OWT.GEOPROSe.HYDROPUNCH,wlr o-+�uceR,OTHER) ❑IEsrnucnal MHOOse TYPE MR.OW) <br /> 0SOL BOROMvt� O GROUT <br /> 'OTHER s GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE Of WELL <br /> 0 MONITORD4 JQ HOLLOW SEM Duh.OF BOR04OLE G�� 11 13 A LTI LE Cis❑WknI VEL WELL CASW4 DLk. <br /> ❑EXTRACTION ❑AIR►Na� MCJ <br /> 70RIVEN CAMW TWESS! LJ 'LD TYPE OF CASING:❑STEEL PVC ❑OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL—lb TREK TYPE TO BE USED❑ALX9M❑HOW <br /> ❑NR SPARGE/OZONE 0K POINT(GP OR CPTH_GROUT SEAL PUMPED:❑Y« ❑t(NOTE.MA)WAM FREE-FALL DEPTH IS Joy <br /> ❑SOL DORM ❑MIND AUGER GROUT SPC-CIFI ixm 1Db V'[l AA.ACPA-V1, <br /> ❑OTHER O On ER: APPROX BORING DEPTH �'3S V rkA C,_! 61 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CoNmcrm CASNOmposiD MYO,od,ptmookm Y,mn,- rdaM <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 VVOFWW HOURS NOTICE REQUIRED FOR DWECTHM <br /> 1 Iim-a"ow ft that I how p,spsnd this ag"cadon end that the work will be dom I sceorda,hp w*son Ja mpda C"*0Mnenoas,Rules and <br /> RsErtat4,40m C ilos wsSWned TlCn �y <br /> —G <br /> PrtNanDole, euS r�I a <br /> 6—O <br /> / T_—DEP R U E Y <br /> � <br /> SITE MAP IN UNLIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: d <br /> dq <br /> APPLICATION ACCEPTED BY DATE ISSUED O AREA <br /> GROUT piSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> ACCOUNTING ONLY: AID s FAC s <br /> PE Ct>Oti FEE INFO Aur RmwrrED CHECK s/ � RECvl)By DATE PEIMfTMERVICE s WVO10E <br /> slitC-57 NAC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERM TT DOC <br /> IT <br /> I3,D7aat 11a4MFS1 YhEiLPBYI <br />