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Vol r lr I rl r LUUK rAl7t F7 <br /> 4INVI,R(of, <br /> San Joaquin County <br /> �onmental Health Department SITE <br /> 304 eber Avenue,3rd Floor,Stockton, CA 95202 MITIGATION <br /> v A ' —009.468-3449 Fax (209)468-3433 Web www s�gov org/ehdUNIT IN <br /> I�-;, � r�Well Permit Application <br /> HF <br /> PIE_:R ,j r� IjLZfVC 0 FUNDABLE PERLUT EXPIRES 1 YEAR FRO_NI DATE tSSUFO <br /> Application as hereby made to San Joaquinounty fora pemtlt to wnstrucl andlor install the work descnbed This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 8-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> WELL LomUon Joe I F,.`(OSE M IT Ari E, Cross street RAYL4w AyE_ City MA NTE CA Lp 9533 6 pa e m <br /> Owns <br /> PROPERTY <br /> ING Addressp94516 Phoned Cst5) 945- 1158 <br /> C•6TConlrad M1TCi1�LL WktI(%Address 3300 MYRTLE AVS. city jVAEKAzjp a0jLIcx6l1Prlonete(104)444.9040 <br /> RAnChe <br /> „ConsultarH/Sub Cnir R 4M AG E E AV, I NC. Address F OL SO8 69 CltyMlllt IETA Llc#LAG 58 S 6 Phone# E916) -_315 0 <br /> GIS Coordinates x Y Township Range Secnon <br /> WORK TO BE PEREMKRD <br /> NEW WELL!BORING (CPT GEOPROBE HYDROPUNCH,HAND AUGER,OTHER') p DESTRUCTION (choose type below) <br /> p SOIL BORING# _ H OVER-BORE DIAMETER <br /> @ WELL# MtW- D PRESSURE GROUT <br /> Q`Mer GROUT SPECIFICATIONS <br /> COMMENTS _ 11AE 0 H-S 1TE MOKITWH rrW lt_ <br /> TYPIR OF WALL 1! TALI_"ON TYPE OCTiON SPECIFICATIONS <br /> @ MONITORING I HOLLOW STFjA DAA.OF BOREHOLE$rr a MULTIPLE CASINGS 11 MULTI-LEVEL WELL.CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SC 4 C TYPE OF CASING 11 STEEL @ PVC Q OTHER <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL It' TREMIE TYPE TO BE USED I AUGERS p HOSE <br /> ,AIR SPARGE!OZONE 'PUSH POINT(GP or CPTIGROUT SEAL PUMPED "Yes ,No (NOTE- MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING j]HAND AUGER GROUT SPECIFICATIONS NEAT C EMI D AT <br /> a OTHER D OTHER APPROX BORING DEPTH 30' BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N0 (d YES,list specAradons in comment section) <br /> COIIImENTS KAMIAGE ENVITkol4 ilATALyrORh PLAN, OATaD._IC(7zro4 -- _ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 46 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable Calrfornla State Laws. <br /> Signed„ TitlelCornpany C 09 S V LTh lk A A('rE E Dlvr 114 G <br /> Prim Name T aS E P IA R A M R 1`E _...._ Nte 'L Z 0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Appli",on Accepted By ` t t' �J Date Issued_,,.`3 � /��a� Area <br /> Grout Inspection By Data Final Inspection By Date <br /> Destruction le"ctlon By Dale <br /> COMMENTS 1 CONDITIONS <br /> ACCOUNTING ONLY AID# FACit <br /> PE CODES REE INFO AMOUNT REMITTED CHECK# REWD BY D E PERMIT/SERVICE REQUEST p INVOICE <br /> 3541 g� .d 3 3 o SR# Ub <br /> C-57 WCT-WAIVER_,._,,,, C-57 Letter of Authorization to I n t Encroachment doc_ <br /> E.HI] 4 02-00I <br /> 6122/04 <br />