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SAN.JOAQUIft COUNTY <br /> --' ENVIRONMENTAL.HEALTH DEPARTMENT » <br /> :;.. BO©East Main$Wet, <br /> ..,.. . . Stockton,CA O2-3029 <br /> Tel(10017e:� � ����aXS��$- 3 Web:wWvaIm:a►alghd' Sl�'E UN1N1�fTTCiIV* <br /> fK3tV <br /> WELL. & SORI NG PERMIT APPLICATION <br /> TION <br /> F.OR 1T a LS.A BOR-INGS'USED FOR MONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE P ff%k EXPIRES I YEAR FROW DATE ISSUED <br /> is:tt qpy awe S Jgaqutn County for a permitto construct and/or Well the work deacAed. This applkatlan is made in compliance with San <br /> da kl tunty:[7 kRpmeM Title,ClrslpterQ-111 :3,grid the Standard's of the`fian Joaquin County Environmental Health'Department <br /> kr Locafto—25-:1a Omierlao Rd Cross street K.n I berg-St. CRY.Sfr CKipn Ztp 9sa oYL APN 1014aAjo <br /> v t_L gQs-Bence prIAO + City ebbs Zlp 3L Phone AiIA <br /> 4m*b b RD.?201 Aag (,,;ityUc73DD�d pi`m*- i6,-qqD.0333 <br /> i oTaaf a r }Gll.!t-hinIrl Address _� SSq CRy Ltc 7 Phone9lb,R4[�.0333 <br /> it . a ,,�1 be- 5c ha&f Address •o. 13ox ?330 City VeAxrf zip 9 3oQb mwft a _64.2 j <br /> rabas:x Y <br /> F <br /> D lfW WE. <br /> 3t0Plr GEdPR6W H'YOROPWNCH,HAND-AUG9R,0MR) <br /> -- <br /> WfiL.41C)s <br /> gTHE�t Itis <br /> TWE a`ie KWEIIAW Q MII<TAt.I.Et ON TYP>r 00RiiSTftUG71.M t IFICAT iDNS <br /> —0 MOWTMW 0 HOLLOW STEM DIA.©F 90REHOLE (3 MULTIPLE CASINGS O MULTI-LEVEL WELL-GASiN0 DIA. <br /> _L7=E)trftACn0&,V0dd Water E3 HAMMEAIDRIVE'N CASING THICKNESS _TYPE OF CASING: ❑-STEEL ©PVC d OTHER, <br /> _I�;S N Vf1f' Ii t'1 eE Q.MUD ROTARY DEPTH OF 0I4pUT SEAL TREMIE TYPE'To BE USED:Q,AUGERS Q HOSE'0 PIPE <br /> _Q$71L t;IdittNtb` Q PUSH POINT(GP/CPT) GROUT SEAL PUMPED:.D Yes 0 No(MA)OMUM FREE FALL.DFPTN IS 3r)FT) <br /> _..C)INJM'TTON Q NANO AUGER GROUTSPECIFICATIONS <br /> _00THERt ❑OTHER: APPROX:'SORINGDEPTH D BOLTED TRAFFICBOX OR O STOVE:PIPE' <br /> CONDUCTOR WING No 0 Yes:Casing t3la: :Caslttg Depth: BbAng.Dies <br /> MATE. if Fwm W A"RINGS'REQfJ IRE,AC4yI S AOMMENTE Oft ENCRC>kACHMENT PEW ff8 <br /> Q WiMUCTM AM TO IN : TAM,'19b III MMD:-(CHECK ALL THAT APPLYI <br /> <_,_/ �FcfF�)tip sE a�oYEO Q OVER-BORE DIAMETER of 3NCHES TQ DEPfH of FT <br /> SIVEt.L lam:' Lr7'PRESSURE GROUT 70 oEPTtt of 3 Fr�lflNt+SUItFA� <br /> Gt�k3tlr SPI�CRF)CkTit3lilS �f��� ❑EXPLOSNES t'TttaM To t=r't3ELON1 SURFACE <br /> TREMIE`T't'#?E Tt�BE tJ�D: kUGIi:RS O"SE PIPE �MUSHRO4fM CAP A7 4�3 FT} pi't3ELo�t'stiRi'ACE <br /> �IlIM6NT8 <br /> TWOM OA"`Nt'Ti0E REQUI ED"(AFTER PERMIT F3S4JANOt) FOR IN6109CTION APPO. <br /> kl I WOMS <br /> 1 <br /> ns �r+�rt'. 1.lants�reparetR tltRs appltcatkrn atM tF►at tltevsak Wllt.tietlane:in aecordanaa vuith vet Joaquin County frRtnstlst>Rules and <br /> R,tiSpaRlEromt;att�ai h# Allf rata,Laws. <br /> -e7 0TRie/Cgmpgny <br /> Pr7iwt.Nse#ie H&I 4115en Date 3 I ) <br /> R9" t M T USE QNLY <br /> $rm, igi;'ll4I.UW IV FIS ADDRESS�37 6. ° l aF'S.�P �o� =RO57`i_ <br /> ullfl I DATM:?7 <br /> t <br /> APPtdCAMON AOCEPTED 81' DATE ISSUED I AREA. <br /> Gf T`1N$if=0N:sy FINAL INS ECTp,N BY DATE_ <br /> DESTRLM' IN INSPECTION BY DATE.W10 'Z <br /> ,ACC 1NTM".LY, :.AID# FAC# <br /> SERVICE R4i4 <br /> Pe 00-DE8 FEE INFO AUT RERAiTTED GIiECK:# ttEIC1/`D BY DATE REQUEST, PR:# INVOICE <br /> 35Az a tom . l 2 5� 3120 . rw L- 3 S 6 <br /> 375' Rn:# <br /> PR# <br /> 29N <br /> C-57 INC WAIVER C57 LETTER OF At1THORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />