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I1; 30i 2004 09:50 209-779-2225 YMESTO ATC PAGE 82 <br />ORIGINAL E F�� T <br />DEC-- UP— <br />WELL PERMITAPPLICATION FORMSITE <br />NVIROi <br />SAN JOAQUIN COUNTY MITIGAMN <br />ENVIRONMENTAL HEALTH DEPARTMENT (EMD)`_',9M UNITTINS <br />304 E. W41ber, Third Floor, Stockton, CA., 95202 <br />("9) 46E'449 <br />�•,�•••.. G DWJ rr snrvy 1 YEAR asum <br />l twe eP011cawn n made In CoMPRISr s Math Sen <br />.CDpIICOCQ, Is hereby Meda t0 r3an Jcsaeu9n CauMY fOr a Oeflak Oe oonafluAef101or a,.ua the wAc desertbed. 1 Masltl, Departtrrnl. <br />Joapuin Cainly Derycpment Ttne, Ctvgtar G-1113.3 and Mi�tr+�a Cf Stir Jaqutn C;ouMY Env!roM+�+� AaeMsors <br />~MLLLocatlole G• iT �thc ss SSwrat�i"t cAjl aD -+2-—PerarM <br />PROrER Address Ctrs M... Ove CkY T✓•�sv ZID?honeN•iTl� 7f7� <br />.'sumer <br />G37 cantractor��e�y .%li:•,.. Addiesa S"S� <br />IV k" t2� Cityyur� 21D OIL L��bw�! a►,onel► <br />cans„na„t/ Sut ^rtr as? 1 Aadross iaN. aClNlt it PAonsrM �'1• S��-�t� <br />We Cmrdhalss: X . Y_ <br />Towrst* I -k S --ice• '� S +c Sactiort _ I lit - <br />i <br />NtcYY'tiELL i BORING (CPT, <br />ROPUNCH, HAND -AUGER. OTHER-)� oose"4�) <br />DESTRUCTICNE. <br />EIL KM!NG D s <br />_ O ER <br />C PRESSURE GROUT <br />WELL <br />C ,Oth- <br />_ GROUT SPECIFICATIONS <br />COMMENTS: <br />89.00 89.00 <br />r I'SRS '70-T0:-24 <br />j jPj oP MVELL <br />p MONITORING p HOLLOW STEM <br />DW OF SORtEHOLE V 0 MULTIPLE CASINGS 0 MULTt_LEVEL WELL CASING OLA: <br />0 EX'iRAC IGN 0 AIR H/4UMER/DRIVEN <br />CASING THICKNESS "A TYPE OF CASING: 0 STEEL (IPVC Q OTHER'. <br />VAPOR p AAUD ROTARY <br />DEPTH OF GROUT SEAL a TREMIE TYPE TO BE USED: O AUGERS p HOSE <br />AIR SPARGE/ OZONE ;11!1USH POINT(!!5E)r CPT;GROUT SEAL PUMPED: C Ya -1 C No (NOTE: MAXIMUM FREE -FALL DEPTH IS 341) <br />^SOIL BORING 0 HAND AUGER <br />GROUT SPECIFICATIONS <br />Q OTI-iE R: n OTHER <br />APPROX. BORING DEPTH D sOLTIED TRAFFIC sex ar C STOVE PIPE <br />CONDUC'OR CASING PROPOSEC IIf YES, UN specAcatlons In xmmard section) <br />COMMIUM: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REOUIRIED FOR INSPECTIONS. <br />I hereby certify that I have prepared this application end that the word; will be done In sccordence with Son Joaquin <br />County Ordinances, Rules and Regulations, and all applicable CaiRomis�S"ta�te Laws, <br />SlgneC xGr —gni L t%.Lraa<.r.'&ll7d*M—Pam <br />Print Name iso” -1 M r! __ /Dotelt.r a Date &X291i7z/ <br />DEP68IMENT USE ONLY <br />SITE MAP IN UNIT N FILE, ADDRESS: <br />WORK PLAN DATED: Apr;) <br />1 SGran+ <br />L;ne- Rj <br />AMAcstien Amsptad B r 1 D.% Uswd `) ' Mea _ /4 5 <br />Grout hapecua 8 Dots 1 • 2 • Q, al IirspactSon By / 7. - Z a7 T <br />Destrvcglon Ineoawon By Dees <br />COIIIMENTR 1 COIipITtOril: 1L(f Y Q 2 �r e D DY U 2 SD i t 17 rr i '_ A S S R• 4• -5-.-6 <br />ACCOUNTING ONLY: AIOR FAC4 <br />PE COOPS <br />FEE INFO AMOUNT REMITTED <br />CHECK 0 RECD BY <br />DATE P <br />INVOICE i <br />35-0 1 <br />89.00 89.00 <br />r I'SRS '70-T0:-24 <br />C-37,__ 'WC`-WAIvi=R_ <br />C-37 I.etter 0 Authorization to sign perInii�_�roochment dal:�4/30/02 <br />p00[n SUTITTjo pase,poo,M OoCttL£LOL 1vd Zt:60 b00Z/04:, TI <br />