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473112/2763 i0:46 20945630.33 <br /> FIFTH F00R <br /> lod <br /> PPLiC�1Ti[�i� �O1�11� SITE <br /> WELL PERMIT A <br /> I� <br /> SAN <br /> 4 TAL }HEALTH DEPARTMENT (EH1L�) M MITIGATION <br /> ENVIRONMENTAL UNIT IV <br /> 304 E.Weber,Third Floor, Stockton, CA., 95202 - <br /> _ (209) 468.3449 <br /> t , NDASLE P>=1MIT�7{P4 E9 YEAR FR M DATE ISSUED <br /> apgAppll0fl o nthyrer everAslapdo to sinn ment Tit�IChs2pteG9-1915.3 anO heI Sta dards 0`Sar Joapunl tcounty Env$nmental Hea(thlD en�de in cornpliancG wlth 52n <br /> 4 A5Sc3Su0'. <br /> 19 51 N or-n. Nw 9 Craas street luo bre" cttY ''J qA S 2 ZO Parcel#b 13-��o-S/ <br /> WELL Location 4$lId <br /> PROPERTY Owner e-srer, CiAl ',i N Addreaw, <br /> �g9Z.S IUar7t. 1��,.+�' `]�City.l"rc Jh o� Zlp Phane� <br /> C�7Contractor�4 L ^l 1.ASSOCAddress`�Z 11/1�ouS�hN "�N. Ciiy LnD► _ -rp 52 aU11c R�yRhone#24q. 3 7.370! <br /> > . . <br /> Cansuitant!Sub Gi11 r'^a� Address C--,a City Sir u Sqi Ph0n0# S A " - - <br /> 1. A - -Section 5 <br /> CI6 Coardinat�c:X� Yr Tawnshi D ' Ran A 4 ,- F <br /> 1ALO tlK10 BEP RFORME : IF17EST1tUCTIAN (ChIIIISC typo t:elOw) <br /> O NEW WIELL f BORING (CPT,GF.0pR03F.HYDROPUNCH:HAIIID-AUGER.OTItERA} 0 ,0 OVER-30RE. DIAMETER <br /> BOIL BORING 11 q PRESSURE GROUT <br /> VYRL# GROUT SPECIFi-ATIONS Ne t�er►�aNT <br /> a-0Lt1er . -.. <br /> COMMENTS: -- <br /> TYPE QF Wel. INS Tl4-LATIDN TY _CONSTRUCTIQN SPECIFICATIONS <br /> q MCst�iTORING �HpLLOV!STEN( DIA.OF BORE _HOLE .0 MULTIPLt CASf;yGS o MULTI-LEVEL"i V)ELL CASING DIA; <br /> ` EXTRAC7ION 1]AIR I fAMMER1DRIA N. CASING THICKNESS _T1"PE OF CASINO: []STEEL p,,PVC Q OTHEr: <br /> []VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TRENNE TYPE TO BE USED: AUORPS q HOSE <br /> �]AIR SPARGE/OZONE a F ij$H POINT(Gr Or CPT)GROUT SEAL PUMPED: q Yes p Na t(NOTE:`MAXIM IJM FREE-FALL DEPTH IS qty) <br /> YSOILSCRINGpHANDAUGER GROUT SPEC:FICATION S <br /> l]OTHER:_ ©OTHERS `­APPROX.SORIN0 DEPTH In RX 3 "L& U BOLTED7RAFFIC BOX Or U STOVE PIPE <br /> CONDUCTOR CASING PROP0S90_-_--' (if IVES,'list specifeatitms in roltrnornt saetlon) <br /> COMMENTS: <br /> ` NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR (ENCROACHMENT-.PERMITS. <br /> 48 WORKING HOURS NOTICE=REQUIRED FOR INSPECTIONS, <br /> I F <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> county Ordin cos,Rules and Reaulations,and all applicable California State Lawn." <br /> A" TIUEe COmp2rly i!¢ Ior y h �llcrr Yb+VT 2n/ 9 S¢►t>I t�J <br /> . Signed 1 <br /> PrintName �7_+`Q6P G-T NICAo/5oM <br /> DEPARTMENT USE ONLY <br /> i t <br /> ., , <br /> SITE MAP IN UNIT IV FILE,A13DRESS: - � - <br /> WORK PLAN DATED: A <br /> ApPlIcatlonAccopt8d R)r -- 1-4, —, Date Ios4ed .3 hl" 03 � - Area f:Sit/f0 <br /> Grout inspection Fina;Inapetitian By .I Date <br /> Destructhn Inspection By <br /> COMMENTS 1 CONDITION 6 <br /> y _= 4-d a <br /> ACCOUNTING ONLY: Ai6o FA 0# <br /> PE coor=S Fa.m INFO ANIOUNT REI4iITTIED CHFX K O RECD BY DATE PERMrr!SERVICE REQUEST O INVOICE <br /> 3 oo .N/—/- 312-tt o&I SR#.00 33t So <br /> C-b7� WC_-WATVER— C-57 Letter.of;,Authorization to siSM.perrnit_EnCrOa.chtnent doc�.. 9/30/02 <br /> _ . DMOVED <br /> MAR-2 1 NO3 <br /> ENVIRONNIBT HEALTH <br /> MAR 21 ZUU3 <br />