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- "05/1712012 0B:32 916339OA94 ATC ASSOCIATES INS PAGE 06110 <br /> 4 SAN JOAQUIN COUNTY ` <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> to lust Malin Strut,Stockton,CA 95202-02$ SITEMITIGATION <br /> iGAYIOrit <br /> x• ztici8 43I3 lr'Vib:vvov+ru s bv.or 1 h UNIT IV <br /> f. — TeTephohe:{208]488.3454 Fav( ) <br /> WELL & BORING PERMIT APPLICATION <br /> r-ORldWELL5 AND BORINGS UgED FOO CONTAMINANT RweSTIGATloNS AND RSMEDIA'NON <br /> Agpfiteal!®n is"by made to San Joaquin COtnny far a permit to ccm mid andlor Imatalt the vredrrtaI;zAbed. 'This•3pptttmian is mado in compll8naa ti ft San <br /> Jo**County IJevaWmant U18.Cheptw 4.1116.3,and the$tandmMs of the San JoECIt1Tn County Ernah'orn vpdal Health[?apartment <br /> 31hk I.ecatian �3�S � 'os5 suet t'i n K P M coy .a.�� `�S1'Z(PAPN U 9C•�I <br /> Pro <br /> ll _ s;rty •zip S_ Pt�etSa V <br /> r�sr pontra r t l JgaGrass tie 124!.`' City��_-YC f I fp Ptlon+a G7 25 ' <br /> cowultant/30 Critr d. Addre9c IIy <br /> lit Party ht S Adam$ Chy - zip,qS .I Pho • 'S'&- to S3 <br /> GIs ada`mnatvs:X—m �f _Y '�'?•"1 S t'l t{��(7Z 3'101`1 <br /> Tro <br /> Ej I+tEW WELLM MHO(CPT,GEOPROSE,KyDROPL1t+tCH,HNNDAVGVR,61MR) <br /> 10 S61 3 Vv"pg�NG'Tb& <br /> WSTAILAY IONS <br /> _(3 monrroRING {3 HOLLOW SMfA oI&OFSCRENOLE— 0 MULTtnp CASINGS tn MULTRXM WlrtLr4SIN0 01A <br /> _CI EXIRAC Oft'VapwrlWAt9r 0 Fr4t4 MERr9RIvtN WING THIOKN zoo _ TYpE OP**imm3 O STEEL ©Pvc•© Oi'HER _ <br /> _0 SOIL VAPbFt PFWSP- I7 MUD ROTARY DEpT.H QE'GROUT$EAL. ____ypiEt a TYPE TO BE VSED: ©AUGER$.0 HO8Ir t7 0im <br /> _aSD•tL 130MRS ©PUSH PCW(GPl tpTi GRDttt•SIAL pjjM*E0:©Yes o No WAYdMUM FREE FALL DM"IS 30 FTI <br /> _O INJEGT10N tyAtm&&LmaW p HANG ALIMM_��GROUt SPECIFrATIONS <br /> OTHER:__,__APPROX•BORING DEPTH ©FSOLTO TRAPFIt3 BOX OR •D 121TOV6 PIP$ <br /> C014DUCTOR CASING D Nb 0 irm!c;aatng vw.,,,_,^coft Depth soft D1c__. <br /> CoiIIIGiI�Nlpr: . <br /> NOTE: OF1:9TE WaLLS490RINOS REQUIRE ACCESS AQREE TS OWENCRO <br /> gP►��IidENTp!lRlVti'�S <br /> DE— <br /> .� �pi= = .CdYER i�U4ME7'Eii OF��aGHEs t't)FEFTI4 f_ <br /> tFC3dFIPf (8}TG � $SURE•G#�0lJT7OLI�PTHOK.,.,�.,..-��E'�O�wStiR�FI.C�E: <br /> IOFI: ifr <br /> GROUT SPECIFIGATIONS [�irKPtO'�`t3+E$FRdtrt�., _TC ,_ FT O Lo*sut*Am <br /> 'V FtEMiE TYPE r+•J BE[]BE17i �+ILJOE:RB HOSE ©PIPE L]i�tUSHROQMI Ca4P kT3 <br /> COMMENTS <br /> 6 WgRKING DAYS NQnC REQtnRED <br /> PERMIT ISSUANCEe�•FOR 1NSPECI IG1M J4PP�?11V fMENTs <br /> 4 haraby th ve preps d this' pitcation end f Mt the wbtk will IO done In'itCcorttancM with Ban JoagtFlti CauntyrOr�iinxricQe,Rules 06At►gvfi o i. 0 a <br /> StB T1tia�GomptYny pato fSCX.{a- <br /> Print � <br /> DF-PARTMENT'_U.S <br /> si#i_NAP 1N UNrT rVFILE SITE ADDRaSs � <br /> WORK KA "DATED .01 <br /> APPLIC"ON ACCBPTtt3(�Y bAn <br /> G#tot r I-NSP,0TION BY _ FfNAL INSFIE 011"lav ---'9ATG <br /> 1]ESTRuvn0N WSPECTICIN Ely A PA <br /> cvinM�Irt�rco:vfiarl3otas: — -D-T� . <br /> pb <br /> A.COGUNYl1 O raRS': AICs FAG# <br /> PE oom I FEE tFmro AMT RENIIITM CHECK¢ RECV'ti NY DATE =2T I PIR-9 IN1/C!C$ <br /> 375� ►� " a 3fab <br /> FIR v <br /> 0-57_ WG,____:WAIVE _'CST LEi I R,OF AUTKORIZATION TO SIGN PERMIT_,,_,6NCROACWMErN? DUG_ <br /> r <br />