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05117/2612 03:32 916339 4 ATC ASSOGIAT,ES+ N`-;� ,-�"i <br /> I� Qt�'' to AGE 61/10 <br /> civ <br /> SAN JOAQUIN COUNTY MAY 17 2012 <br /> ENVIRONMENTAL HrzALTH DPPAFTMENT.t( .,0 -�t,.iJtsl�I;'! LOP <br /> isle <br /> 600 East MWn Set,Stoll t n,CA'95202-31329 ,t:1'zrr; SITE MITIGATION <br /> tre <br /> • Telephone.(2M 4684454 Fax.,-(209)468=3433 Web:wvv+kri]j�D�*"� �4d' -1•2 UNW I1/ <br /> WELL & BORING PERMIT APPLICATION ` <br /> FOR WELLS ANN$ORIN08 USED FOR CONTAMINANT IwtvIGAMNiS AND RtMEDINnONI: 19VL <br /> N- E [5148L S ErD - <br /> Rppi'rcatign Is I+sreby made to Sart 10wiuln 0011ft Far a parmitto=mtruct anrf Instal the wwork•dowbad. Thli dpplicatipn Inmade In carrlpllante wfth Sart <br /> JosgOEn COUnty Devebpment'Titla.Ohapw-9-11115.3.and tha Standards of ttta San daaquih Guanty Envimmar t Health Dapartment. <br /> $!te'Lacmfv" b11. 1 me fCrc s 3t 3t L9�1. t 1h e� Cts _ _.Zip �V)�o APN <br /> P"" 'I Lp <br /> o V dr w U15 'N-. til VA, clig�w- zP-91-2. <br /> C�!•Contractor�d >O�t[It Addm%S 0sm. city IJc Y 1-�', Phone L �ot� <br /> consttUnnubOhirtte_Aj2r_A Address 3t=-tAAdtSar._sty�.,�io�tty,.j�► ,�IisYt�lc�l*hoo Q_W � act .04fZ� <br /> BUlsbl*.Pm'ty &noCO�RAi w.S AtMIms "� ad+n city v>•+jah Z.0 [ PhMa a.i.lap sem• 1 <br /> GIs CoordTnatam:'ylam• S _.Y 'L i <br /> ON qN W BE <br /> MEW WELUBORINGf-COPT,GEO?R09F�NYDROPUNCH.HAN0,AUG6R,On EM <br /> �UYE1.L f� N�If39 --------------- <br /> OTHER ID6 <br /> IUALLAM"TYm <br /> _t3MONtTORINCs Cl w�,LOW STEM 1510.OF l3GRt7IOLE ritULTIFI.E CASINGS❑M�Ut,TM�LevEL WEl1.CA M DIP <br /> fO ExMACTION:VaPeNwater ❑HAMMEKORWEN CASING THICKNW* —TIFF OF 4SING C?BtEEL C�?VC OTFIER _ <br /> _C3 SOIL VAMR PROBE ©MW ROTA Y Mm OF GROU ,$F,AL��–--TF�MIt:TYPE rOHE USED-,10 Allt3ER9 LI KOSE E3 PIPE <br /> _Q SOL WPJNG fl Pusfi f'btw(Gpi CPT) CA0Lr SEAL PUMPED:,❑Yss ©Nv Odk) MLW FREE FALL Dgn.11'15 30 M <br /> ,INjff&n0Nq,g.g p,- tet t HANOAUGER,r:_._,.GROUTSPECIFtCATIONS <br /> —CIOTHER: ©OTHER: APPROx DURINGOEPTH Irl RMTEITRAFFICSOX OR 'Il StOVE PIPE I <br /> CONDUCt'ORtASINO0Noll Yaw Cajhy01a:—C8ftomph.._ 606rg <br /> am— <br /> COIMIHI^NtIS: <br /> NOTE: 0F1FSI7'E.=[. &BORINGS REQUIRE ACCESS AGREEMENTS 0RtNCkQAGt4MENT PSS ITS <br /> p.&s It w v ERFOR e� <br /> -.'d .aUt`w S}tlDs t} OVFJ�-BgftirDtAMET1rRG* mct+EstooF�01:, ry <br /> YIrELk <br /> PRE <br /> GROUT 7O bEPT!{OFA_(•111EI.WIr suFtFwOP <br /> GROUT SFECIFICATI0 S EXPLQ8IVES I+t .TO ,y tTtaSI C1YSURfdCE <br /> f:h91E TYPI TO BE USEt7 AUGERS HOSE O PIPE ❑�3SFiF�00N1 Ci4fS nT�3 FT► FTASLOW 6tWACE <br /> CCHIAlIIWIV <br /> j 8 WORKINGDAYS NOME REQUIRE01AFTER PERMIT ISSUANCE}FSR INSPECTION APPOINTMENTS <br /> I hembyeIhm t props applkatioh 000 tit th*WOYliWill ba don*In 01000ldarm t?trM San Jo*gnin County OrdrrWiDgE,Rglea and <br /> R�platlq ppt t•E I la Laws, dn-a!4 <br /> ad ThlelCalrlp8rly <br /> r p� . <br /> Dote <br /> DEPARTMENT.00FE <br /> 'SITE"MAP <br /> j WORK KAN DATED <br /> ! 4`Pl?I.IGA114NkCCEPTEC3 fY t7f4 O d_DI- 'p <br /> 97 <br /> FINAL INSPECTION I3Y AT r; m! -�3 <br /> GROUT INSPECTION By --- <br /> I DESTRUCTIONINWPEmMIONi91f DATE <br /> COMMtif6fCONDfTE01 I.C/ <br /> A=UNTtNG My' AID fF FAC <br /> 81RRVtGB 3t0# INVOICE <br /> PE C07yFF FEE I{tFC AMT lRAMrrrE0 CHECK4 RE'C!"BY DATP_ RE QUEST PRO S.OZ t25 14000 <br /> �z� s��OO <br /> .d'3 3 7 S- tis 3(0 , <br /> PR itr <br /> C-57 we ��yWAIVER C57 l ETTER-OF AUT HORI7 ATION T4 SIGN PERMIT_ENCROACHMENT 1300 <br />