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01/24/2006 14 11 2094683433 EHD PAGE 02Y <br /> San Joaquin County - <br /> 01 <br /> 4 Environmental Health Depawent SITE <br /> 304 East Weber Avetaue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> • (209)468-3449 Fax (209)468-3433 Web www sjgov org/eked UNIT IV <br /> a WeII Pen nit Application ��i� <br /> NON-REFLINWBLE PERMIT EXPIREG w YEAR FftCM 04`)E ISSUED "/ � <br /> Appgmon is hereby made hs San,leaQuin County for a PBrrrrll to conslru4 and/or Inalall trio work doaerlhed This appGrallals Is,made m mmPgarim wi%h San <br /> Joaqu)n County Dave4aprnont T"tae, heytar 1-?115.3 and thr 9tarxfarda of Sart Joaquin County Entre m"I Hero Deprranent <br /> qj�] Assessors <br /> 1M1fELt Ltspsllon Oros Sl►aet G1Y i9 J..GJ'll�areehP <br /> PROP ( ] <br /> 11 <br /> Owner 'I ddrass !` S• CM _�ip�pnone �,r, <br /> 07 <br /> CW Gonriactar a44roas C� �,�Phan +/��y/ "+}a" <br /> ConauNantl Sub ddras Clty CN— Phan <br /> yaoq <br /> GIs Ccordinams x Y p r Range Ssotro <br /> WORK TO EP EM RMLO <br /> pW WELL/t30RIRi (CPT, HYDROPUNCH.H"-AUGER,OTHER`} p DEVRUCTION (thooau bps below) <br /> l7IL 9W <br /> 0RG Q;;a <br /> QOVER-BORE P AMETEK <br /> )rvzL R Q PRESSURE GROUT <br /> ti-Oth GROUT SPECIFIcAT)ONS <br /> COMMENTS <br /> TYPE OF WELL, nTALt1Tt N 7YP OM T 11 1139CIFICA12OKS <br /> (1 dI0AtROR11ZG 11 HOLLOW STEM 1]iA OF BOREHOLE <br /> _ p MULTIPLE CAS)NQS jl MULTIJ.EVFL WELL CASING DUA.— <br /> 113 EXTRACTION a AIR HAMMERJORIVEN CASING TH CKKsS.TYPE of cASING la STEEL 13 PVC q Q711M„- <br /> Q VAPOR a MUD ROTARY ae:,rx of GRDUT SE1AI-.TitELi(E T'PE TC DE USEI)- la AUGERS 0 HOSE <br /> SPARGE!OZONE YPIJBH POINT(GP Or C n GROUT SEAL PUMPED Dyer. Q No (NOTE:MAXIMUM FREE-FALL 1)EPTH!S 30') <br /> 4rtL 130AING Q HMO AUGER GROUT SPECIRCATIONS <br /> I2 OTHER,- OTHERl��,_ APFROX-BORING Q BDLTED'rRAFFIC BOX or 8 STOVE PIPE <br /> CO t;TOR IN PROPOSED Cd YES,1161 spadllcoUnrns lR comment seWOn) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMI=NT PERMITS. <br /> 48 WORKING HOUR.! NOTICE REQUIRED MR INSPECTIONS, <br /> I hereby cattlfy that 1 have prepared this applicattOrt and thatths work vAll be done In accord9mr-6 w1th Sart JQGQUIn <br /> CalmtY OrdtnaDW,I Is nd Re a ortIs, and all appllcable California State Law& r f <br /> sorrad TltlonCompan !�/' /r <br /> Pnnl Name �G/ Opo <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:�� — <br /> WORK PLAN DATED; -8-o T <br /> ApPhoton Aeceptad By Date Issued <br /> Grvul Inspadl4n By Qa al Inspection 13y Cato <br /> Qeast UC%0n Ir%PBctfon 0y Date <br /> COMMENTS f CONOITIONS <br /> ACCOUNTING ONLY AID* FAC* <br /> Ps COMES FUE IF60 AMOU14T REMIrnM CHECK 4 Rm`O 8Y DATE PEAMIrJ SERIAC19 RBQUESTa INVOICE <br /> � 223 l <br /> 7- <br /> 22 <br /> 1NG-UVRIYER____ G57 Iter of Au?horrzatlon to sign perntlt� >:ncroachlntrrt(clad <br /> Lau?9-trz-fw r /J <br /> 6/aW4 Y <br /> TOTAL P-02 <br />