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11/20/2004 01:50 -109-E79- '2225 MO T AT ; u U I 03 <br />ORIGINAL <br />DEC 12004 <br />WELL PERMIT APP1„ (CATION PORK_NVIRONAITE <br />SAN JOAQUIN COUNTY FERMI- AITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHO) UNIt IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(200) 460-3449 <br />N2m R eRRam t3StllAtlta t nanca * tb Sen <br />Applicfora to aolrtruat adder Insltll the wom tlMerboo. Tr" epFlso ttatlon ie mace In xmp <br />joacuatbn is County <br />0*v mads to Sao oeeuln County P Envoomnental Heatth DeP�^�rt- <br />Joeculn Canty Orvttopnvnt'tiue, Ct+aotiK `�� t 15-3 and to Slaneards at San,loaauin County 99 j P� 2 4 3 S o0 4 <br />WELL Loealbn <br />t5 E i L'�s R.L Cross Sb1W a' ' r y C-- <br />taRCPlRi7 ne� Z1P91�4S p,� 1t,'i� <br />Address 2soL-4 Vtk:�,� �}• c`a f A.►,�� ✓e�� <br />Addre" bw- RCvr.g-L city_ <br />c-37 Convector <br />bcity .'{a <br />GonsuibK r Sub Cntr C r Addna <br />r` <br />Sia Coordimatme. X <br />Y Rance R WORK TO M IZMNM; <br />5 E Section <br />KNEW WELL / BORING (CPT. oPR OPUNCH, HAND AUGER. OTHER") p OVER BORJ<.CDIAMETERcose type �e>aw <br />` oal- BORING N Sd 1 p PRESSURE GROUT <br />Q WELL N GRouT SPEC:FtCArONS <br />p -other <br />COMMENTS: <br />'YPE 2? WELL INSTA LAMON MMI <br />o MONr l ORIYG p oLLOW STEM DIA. OF BOREHOLE i' p MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DW <br />p EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNES5If <br />TYPE OF CASING: Q STEEL 0 PVC aOTHER <br />p VAPOR p MUC ROTARY DEPTH OF GROUT SEAL 6 TRemiE TYPE TO BE USED: Q AUGERS Q HOSE <br />p AIR SPARGE' OZONE )OUSH POINT W or CPT)GRCUT SEAL PUMPEC: p Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301 <br />ROIL BORING 0 HANC AUGER GROUT SPECIFICATIONS <br />p OTHER: t1 OTHER APPROX. BORING DEPTH p BOLTED TRAFRC BOX or Q STOVE PIPE <br />CONDUCTOR CASING PROPOSEDAIS_ (K YES. It spodke ons in comment section) <br />=&UHWM: <br />NOTE: OFFSITE_ BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be dons In accordance with San Joaquin <br />County OrdInnancos, Rules and Regulations, and all applicable California State <br />L�awws.� �y� /+,� <br />Signed x_42=414'19 . ��_TItINGomaelryr G-�Oc-A/m0 1��t,111 Vl c (2 . <br />or!nt Name L.Qr1�: ✓1 C �. fw.�Clot.Uldi�S'1 Date / / 1x19 /n Al <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1 S E- . Gres»+ I- I Ti G R oa d <br />WORK PLAN DATED: Aor lI I►J9� . L 20 Q , <br />Awo.mon Accepted By �. M G(. w, a Dab lowed a - -0.4 Area /4E 9, / <br />Grout Insoectlon By /Z Z <br />Destrucaon n 0Iv Date S B -1 <br />COMYENTs 1 CONOITIONE: r` S <br />ACCOUNTING ONLY; <br />.IDN FACA <br />Pe CODES FEE INFO <br />A110UNT REMITTED <br />CHECK a RECO aY <br />DATE P CE REOItE INVOICE <br />3,501 �Koa <br />I '94.00 <br />I <br />Q SR*C'oZ�C,;2r <br />C-57_ WC^•WAIVER_ C-'.57 Latter of AuthoHration to sign permit! en r 4/30/02 <br />mQ1 SUTTITU4 A•113,++P00,1{ 00£6b_£L0L XV3 T6:60 6002/0£/TT <br />m <br />