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SAN JOAQUIN COUNTY <br />—.w <br />ENVIRONMENTAL HEALTH DEPARTMENT LOP <br />SITE Mfi1GATiON <br />�. =y 600 Easl Main Street, Stockton, CA 95202-3029 UNIT N <br />gam- Telephone: (209) 468-3454 Fax (209) 468433 Web: www.sje7ov.orc 1.1 ehd <br />WELL & BORING PERMIT APPLICATION <br />FOR WELLS AND BORms USED FOR CONTAMNANT INVESTIGATIONS AND REMEDuT10N <br />NON-REF1INI}ABL£ PERHT EXHI:CS I YEID FRQM DAM ISSUED <br />Appicabon is hereby made b Son Joaquin County br a p " b corWAxi and/or n" the work described_ TbU app liralm is made in compliants wire San <br />Joaquin Coaly Development Tine, Chapter 9-1115,3, and ft Standards of one San Joaquin County En*onmerdal Healh Dapadmmrt. <br />SRO Location 75 E. Alpine Avenue Crass sk g N. 8 Dorado Street <br />prop" Wendy lot Berndt Truest _ Addlem PO Box 1610 <br />CSf Contractor Woodward OdUffig Cc Address W FVwwRmd <br />comwbnusub entr Carina ERF Addna= 601 K NcDowed Boulevard <br />Billable Party Cardno ER! Address 601 U McDowell Botdevard <br />GIS Coordinates: X Y <br />�j Stoa3dan Tjp 95204 APN I15440—G7 <br />City Ap1ao yp 9§901 Phone <br />cjW Rio Vista l _ic 710079 pk", 707744300 <br />City Pima tic Phone 70`r 76&2000 <br />py Petaluma zp 94954 phone 707-766-2000 — <br />CONSTR CTiON WORK TO E FOiiM EQ <br />NEW WELLMORM (LFT, GUr]P7+ZfSE. it1DRpFglNC9n- it llrAAl7GER d71iErQ <br />$OIL 13C' %r, ID -S <br />WEI.t IRS AS I Ihruert,(In AQ, A85 a thromh SVE3. SVE5 and SVF6 _ <br />❑ OMER IDs <br />TYPEasoFmnLmmG <br />MMAUATMTYPE <br />_D LIM&MRING <br />OT HOLLOW STEM <br />5__®EXTRACnON: VAW WAw <br />D n rl+artrWN <br />—D SOIL VAPOR PROBE <br />D ?" ROTARY <br />—0 SOIL SORMc <br />Q PUSH P10w PVCPn <br />�01NlECTIONr..ar9�om.n(7J•w1DALRi6t <br />_ <br />_I] oTrot <br />13 CmM <br />DW OF OONOME 9 D ma71I7E cAs 17 nta me6vL viaL cmm DIA: 2-mh <br />CASINGTHICKNEsa SslleiftftQ TYFEOFCJ1 M DSIEEL NPVC D OTHER <br />DEPTNOFmwrj*AL 39 7REW7VPET02EUR?Dt DAUGERS DI+DSE OPM <br />G9OUTSEALPURFM0Yes Otb4UAXVUlrrFr�EFAALLLDEPTNis3oM <br />GROUrSFECPICATIONS 1—a-4 Jp EA!T_— - - <br />AFFROXSOWN DEprII 40 139OL7ED7RAFFICSOR OR t]STOVEPIPE <br />CONDUCTOR CASrNG ISM D Yes Cashy Dirt ramp mItty B-9 Dia <br />COMId1:NT$: � wws sap tie ac,rcnaexn (rwa n.nU see.aa.: uc+l::, a e-�wnu.s urrgl u+at sr, ora re ku c� Hrrmrcn�auH+�.bae...ewr.. [yu.evyn�]smaznren.. pq. a �'.Tofhe 9oa <br />NOTE: OFFSITE WELLS S BORINGS REGUM ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />DESTRUCTION WORK TO 13E PERFORMED: Dmm71m M€y—&-.iP*2s h+ -t- T—TLk P n <br />it OFWEU(8) TORE DESf ROYLD D OVEPaMIE DfAh1ETER of WMIFS 70 r>EPTH0( r r <br />WELLIDS: ❑ PRESSURE GRWTT0OrPMCF Fra>:uasVUWAs <br />GROW SPECIFICA7KMS © EXPLUSPIES FROM To F76ELOWSUWACIE <br />TITERTYPETOBEUSED :❑AUG£RS ❑HOSE ❑PIPE DWSHROOMCAPAT0Fl7 FreeLvwsu FmE <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />I holt certify Oral 1 have prepared fids appli atlon and Out On work vim be dare in accordance wit Sar Joaquin County OnNnwmw-% Rules and <br />Rumps, and as applicable California laic& <br />Signed --ca,�, t re <br />Tmep" 1 7 <br />Pa1Name� p.(l <br />DEPARTMENT USE ONLY <br />SITE MAP m uNrr w FILE -Slit: ADDRESS <br />WORK PLAN DATED C VL ilk <br />APPLICATION ACCEPTED 9Y IA1]CLAt.^ c 0+�1 _ _ DATE ISSUED e r AREA <br />GROUT INSPECTION BY F&ML INSPECTION BY I IF 1147E <br />DESTRUCTION INSPECTION EY DATE <br />C0MMENTSX0NOT W-, <br />ACCOUNIINGONLY_ <br />AIDS <br />FAGS <br />PE CODES <br />FEE INFO <br />AWr RENn7M <br />G1ECKi <br />RBCYO BY <br />DATE <br />SSEO <br />REQUEST I <br />RD <br />IHYOICE <br />5122x IO <br />�J tl y2.0.00 <br />1 o 3� L <br />(,+ _ <br />, - <br />I' i <br />—,--: -- <br />- _ <br />SM L7-101& <br />x.403 <br />66, 0 <br />RO 9 <br />Ro s0 <br />- <br />PRO <br />457� _ WC WAIVER C-57 LETTER OF AUTHORIZATMTO SIM PERMIT ENCROACHMENT DOC <br />CHU 29-01 mra-w10 WELL PERMIT APP <br />