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PAGE: e2— <br /> �ECSJ <br /> San Joaquin County <br /> IdA a - xq, dt <br /> vironmental Health Department SITE <br /> 304 Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> Pin <br /> E;?^���/SE�i�IIC�� Well Permit Application <br /> �In V O4 A*_1k q9 Fax (209)468-3433 Web www sugov org/ehd UNIT IV <br /> P <br /> NON•REFUNDAB"PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ApplIC4*"rs hereby"de to San Joaqu,n County For a permlt to oonsiriret aodlor,rule,the work descrlled This application m made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Erwtronmeml Health Department <br /> poiYRtE flRopEIt7Y WRST OF Assessors l� <br /> WELLLeentlon 001 E.`QOSEMIlt AVE. Cdos9Slreel F-A(LOW hV1! City MAN TLCA Zip 95335 Percew Z��TVQ9 <br /> f <br /> R Sri y0 .ern. Q. <br /> PROPERTY tdAN l+10RFAK _3$P �$ <br /> Ex UIY L LA Ax A LEC Address �•0.6 Q% 22 6 Q Clty H l l Zip 95 0 hone# <br /> Owner j <br /> c-s7 Contractor.MI%dg i.L 01%1LLiti11r Address_�9aa MYR_T_Ll AYE ._ CIty EYAE KA Tip 5 a i.rds040:f Phone#C±Q4 4`�' "40 <br /> ConsultantlSub CntrAMAFE: E_h1V, TRIC, Address_P4.6dX669 CityMValcHe <br /> , ,_-..._ Lrc#R S BS ro Phon¢# 916 35'4-3 5 0 <br /> GIS Coordinates X Y Townehrp Range Section <br /> WORK,TO BE P_EREORMWI <br /> I NEW WELL 1 BORING (CPT GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER•) p DESTRUCTION (choose two below) <br /> j a SOIL BORING# U OVER-BORE DIAM6TI=R <br /> WELL# NW-%.14W-9 1)PRESSURE GROUT <br /> (]'Other GROUT SPECIFICATIONS <br /> COMMENTS Two b snE MONITOR KCr WtLL5 Accgss Pt SMISSION LE Ttit TIACHIrD <br /> TYPE OF WELL INyS' W LAMON TYPE <br /> E MONITORING S HOLLOW STEM DW OF BOREHOLE-U! 0 MULTIPLE CASINGS d MULTI LEVEL WELL CASING DIA 7 <br /> p EXTRACTION AIR HAMMSPJDR1VEN CASING THICKNESS St;H '+0--- TYPE OF CASING U STEEL E PVC D OTHER <br /> O VAPOR U MUD ROTARY DEPTH OF GROUT SEAL Ill _ TRtEMiE TYPE TO BE USED I AUGERS a HOSE <br /> a AIR SPARGE!OZONE 13 PUSH POINT(GP or CPT)GROUT SEAL PUMPED 0 Yes I No (NOTE- MAXIMUM FREE-FALL DEPTH IS 30`) <br /> U SOIL BORING 13 HMO AUGER GftOUT SPECIFICATIONS HEAT C EM E K T <br /> a OTHER Q OTHER APPROX BORING,DEPTH 30, E BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N 0 (If YES Ilsl speelAealions in comment section) <br /> cOMFAEM: RAt4ACE ENYIADNMENTAL WOR% PLAN, QATLO 1011110 , <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING FLOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that 1 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 California State Laws <br /> di "�— <br /> Signed x ` p "i�� milecompany Ct;µs u L T R M h(r r-N V, INC. <br /> Pnnt Name 7 0S E e N E A M&G E- Date_ '11-Ls I 0 5 -- - - - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: `/ <br /> Applreaifen Aoceptad By i~� (�`�, Dale Issued _ 3 I J? <br /> zx— Area <br /> Grout Inspeeflon By Oak Finel Inspection ey Date <br /> DestMehon Inspection By Date <br /> COMM>=fdTS 1 CONDMONS <br /> ACCOUNTING ONLY AID# FACO <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK S RECD B� DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3 3 os" sR# �N <br /> C-57 WC_„_;WAIVER-,,,_ C-57 Letter of Autho7Ixf sign permit_,EnCraaehment doc^ <br /> END 29.02.001 <br /> 6/22104 <br />