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Wa�r1e waodw 'I <br /> c`39p and 1 -7[17-374- 56.77 p_ 2' <br /> t - <br /> 86/18/2093 08:(32 2894683433 FIFTH FLOE7F>' PAGE 04 <br /> �] ERMIT APPLICATION FORM SITE <br /> : YELL P COUNTY MITIGATION <br /> SAN JOA¢UIN UNIT IV <br /> .JAN 0 g 2004 <br /> ENVi1ZpNMENTAL HEALTH DEPARTMENT W <br /> ENVIRONMENT HEALTH (209)E.Weber'l'h{D9y X68 31449 ton,Gly, 95202 <br /> PERMIT/SERVICES <br /> RMIT EX ES 1 IMP ti 6Fy <br /> M tR tfNDAB 4llihe work I scrivad. Thls applic"On Is mods In complfirla+with San <br /> �PPd cation is t iefoby mads to San JomlAin GOunb%W■perrt+rt m eonL�WrKu M15 OM"e�rrpl Hesilh dePorb�- <br /> r Asseeanrs <br /> ioaauln Gr3urtb Qe+d}aprnrnl (Me,Chap 9-11145 and 11er 9andarda of Son�oeRu�ln rl 5 <br /> �ir[ p -tD Par> <br /> prEtl t oc�c,on --Lf,-)S "fir+, 'a t u a- Grass smart L�o%.)e e a+y 2 - <br /> ;� . Q uo, c.54 9 c�Iy tl - •. 3 R Cl 5 i. <br /> sRQPERTY owner A#��.�. . - l� nddneee <br /> "�3' carr'.-, 4`i5 `mel?'lti u r,onel'r y <br /> t:�7 Ge(11ra�or l 1C{$6`wil �+f �r��J.J !Jnr!e <br /> no <br /> e �rs `� �i-a�w" DO Cit1f�5 a cam— � PAcndi <br /> cer�uIxantI sob Gntr � �Y Addro �h4vn 6lpr'+th <br /> �� Bastian <br /> 1. .`r4wn91T� <br /> G15 Cocrdinat�:k <br /> wore Ta EmPORME : t <br /> p.RlEllV WELL 1 B047SNG iCpT.CSEflPRWE,HYDROPUraclt,HANC-AUGF-f%,OTHEI�"'j R-aOR Ga01JY <br /> ]a solL BORING A� ��, { <br /> VWFLL>fF_�s5�` GRaUTSP'EcAFIGA7{ONS � T- ` <br /> Q lathy f <br /> COM MEATS: <br /> �t s>`.uc.{'�u•� iDH SPECI OMS - ' <br /> TYpj�op WELL lftvaVE <br /> p MONITORING �lOLLOW STEM DIA.OF BQftEHOI��„ gINULTIPLE C1t61N1',S [I MULTI-LEVEL WELLC»I G <br /> Ll>=xryuGTtpra (�AIR HAMMER/DRiVEN CA�t31NG THICr�ES� - <br /> 'TYPE OF Cd5{NCr. Q Mf-L a Pvc Q umem <br /> 4 VAPOR D MUD ROTARY 06PTH OF GROUT SEAL__ �f _____..r--TREMIElYPfcTO BE USED: Q pUGEl OSE <br /> es p No (N¢TE; MAWMjjm FiMIE-FALL DEPTH{ S 30'1 <br /> [1^1 A SPARG61 OZONE 0 PusH POINT ICP or GM onto 1T SEAL PUMPED:V��� [�►.w� 4 <br /> p N <br /> Q sntu BOR{JG AND AUGER GROUT sPECIFICATIDNS <br /> g7HER �� <br /> APP ROX BOFUNG D 13 BOLTED TRAFFlG 8bX or Q STOVE PIPE <br /> ;f'OTHEr�: �r�n,ttn,tt.l"-q (M 11 6.FittpeilimWens rn cormnerrt xativn) <br /> carugUGTOR cw51NG PROPOSED--_ . <br /> COMtNEaNTS: OR <br /> NOTE: OFFSITE BORINGS REdV RE HOURS Co ECS Eau R1rI3 o�R las ECTtoNS.pCHMENT PERMITS. <br /> as WORWAG <br /> thyo <br /> ls application and that the work yowl be done in accordance with San JOailuin <br /> I hereby certity that i have prepared <br /> county Ordinances, kuies and Reguiatio all aRpila:able California State Levies. <br /> s;9n`x!■ <br /> "Ll-Z) Dale 7 <br /> =r nl rlam4 p PARThIIENT'LlSE O l.Y <br /> 5!r E MAP II4 UNII[T IV FILE,AdORF : <br /> WORK PLAN DATED: <br /> Dare Issur } <br /> App{Ic t;am Acceptsd BY� �• nal Inspection By patL <br /> G,aut 105Perti0rt BY OY� n <br /> V <br /> pns;ruesion inspeebvn BY <br /> CdMMt:l�CS!CONDITWNS:��'_W� [ <br /> AOGOUNT1NGONLY: AID# FACO <br /> PE CODES FEE IAFDt AMOuWF RFm �YtCHECK• 1REC'D BY PATE f 94RVIGE IkEQIlIE5T 4 INVOICE <br /> S az fp a_ Too- 97 1,�� / A SR# <br /> 7,,�;� :w[� wA►IV1=RT C-57 litter of Autkorixatich to siS Perrnl?.�_ Eric in#dei— �J3�IOZ <br /> C}rkl tInRZAtA ATR Yd.� LT:AT '3rl.T. An/Tn ro/ <br /> h L <br />