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U//21/L17I7�) IU:IJ IJ 2b34bH3433 EHD PAGE d2 <br /> ML , . San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor,SwcktOfl,CA 95242 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjoov.om ehd UNIT IV <br /> Well Permit Application <br /> NON-RElFUNDABLE t pMT EKPIRZS 1 YFJUt FROM DATE ISSUED <br /> Application is hereby m&do to San Joaquin County for a permit to CAr%Slrttd andler incur the work described. This application I&made In comoanoe with San <br /> Joaquin County Development Title,Chapter 8.1115.3 and the Standards of Sen Joaquin Caurtty EnvirorernaMal Health Depa m k sons <br /> <.^ O l� Cross SIIbPt ( p Cly Zry <br /> at `�S? 57 ParC81a i 2 f...s C d <br /> WELL Locion <br /> PROPER1YC �twrx4 C2 <br /> � � r �r T. /LdOwnLdress, 1�+o t . t J Q y( : y miry <br /> Addroes(-t'-g« 2Sr� City Gn P3d0n �tl.Srt'gG-�33� <br /> CS7 Cmtractor �• i tZ E- ,lL Plrorco0,I�t�� �� ?�*�' L <br /> CCMLdmnt 1 Sub OnI-z. <br /> GIS Coordinates:X Y^ Township . Range Section <br /> WORK 10-M FERF <br /> Q NEW WELL I BORING (CPT,GEOPIRODE,HYDROF'UNCH,HAND-AUGER OTHER? XDp ER BQRpE I D AMETERw LYpe X0"4 <br /> SOIL BORING 9 a PRESSURE GROUT <br /> WELL tF GROUT SPECIFICATIONS - <br /> Q•Otittir <br /> COMMENTS: a c i{ c_w a c = c--F e o nn r1- -�` - <br /> TYPE OF WF IW3-FAL4ATK)N TYPE TRkEMN SPECIFIQA710 $ <br /> WF-LL CASING OTA <br /> 0&40MTORING 0 HOLLOW 3TEM DIA.OF OOREWXE� I L C MULTIPLE CASINGS Q MULTVEL <br /> Q EXTRACTION d AIR HAMMER/DRIVEN cA31NG THICKNESS TYPE OF CASING' Q gTLEL a PVC p o7HLR: <br /> ()VAPOR U MVO ROTARY OrpTH OF GROUTS TREMIE TYPE TO HE USED: .Q AUGERS VHOSE <br /> Q AIR SPARGE!OZONE d PVSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30) <br /> U SOIL 94RING U HAND AUGER GROUT SPECIFICATIONS .^e r e, '--, C-V'�' <br /> d OTHER' 11 OTHER_ APPROX.BORING DEPThI I-d e —Q SOLTEI)TRAFFIC BOX or (J STOVE PIPE <br /> Qp CASING PROPOSCD it YES Itst spa_c,ificabpns in cnrrynent Seam) <br /> COMMENTS' <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROAcrtnricn'i rcrinAi�; <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> I hereby codify that I have pro Is application and that the work will be done in accordance with San Joaquin <br /> Coutlty Ortdf7nceS,Rules R lationa,and all apPiiCabta CatF:r;m;r S°.:'c' ' <br /> 6gned ice. TltlelC <br /> Print Marne ��-,�� f <br /> �..^ Date v <br /> D RTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED' <br /> � .� p-�-�-� Oaty Issued � Area�Q � <br /> Application A=plTad BY ~ Date <br /> Grod Ingpedion By Oats Fw*Inspection By <br /> Dest action Insnediw By Date 0 Z� <br /> COMMIENt'9 100 KUTIOKS. Q S.-•14 jV <br /> h1 «i <br /> ACCOUNTING ONLY: AIDS FACS <br /> PE CODES FEE INFO /MOUNT REWTTED CHECK 0 RECD BY DATE PP_RMtr 1 SERVICE REQUEST it INVOICE <br /> SIG os' Sjab �{ ��y <br /> C-57�� WC_WAIVER____ C-57 Letter of Authorization to Sigh permit.,Encrocchment doe <br /> EiD 29-02-00L <br /> 6x2/04 <br /> E0/Z0 -AOV8 CM 1Q0 89EtSe0567 Lb=9T 564E/0L/Z6 <br />