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1 <br /> L[E` ;i • • FILE COPY <br /> SAN JOAQUIN COUNTY <br /> GGUCI°'ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> i'6 East Main Sireei.Stocidon, CA 95202-3029 MITIGATION <br /> 't r, F ►{ot(e;(209)466.3449 Fax:(209)468 3433 Web.yv�vsiaov.Drn/ehd UNIT IV <br /> GT rl — <br /> tt WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDI/l 'h <br /> ,Avppircation is hereby made to San Joaquin County for a permit to construct and/or testae the work described. This appi;mtion rs mace in compliance Hath Sari <br /> .Joaquin County D�elveeloppmenteT7TNrh <br /> e, ap(terr G-1 t 1&3 and The Standards <br /> foff�San Joaquin County EnOonnnental Health Department9._ <br /> Well Location SQ'1GLJW•?Amer J'.Cross Surest y� f J iTtX�t city wv t zip q�ZQ Parc#i rso55 zoo 5 <br /> Po,,.•nCity, zp 'SAyPhones 36 .3000 <br /> C-57 eo u aicmrC .�PA r- t _ Adaass X183 W 4St(oUeSe R� City n QoSq Lk a�Q35}�hnna �a} 568 �D95 <br /> Conauttantt3ab Cnac . coy C curt Ima Lib <br /> GIS Coordinates:X V-j7?4.3`t3 ,Tow wNp Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WEtAlSORING(CPT.GEOPROBE.HYDLOPIINCH.NANDA GER.OTNEW) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> 0 SOIL BORING* Q OVER-BORE DIAMETER <br /> ❑WELL! ):\A!- E•VV-"i _ ❑PRESSURE GROUT <br /> ❑•OTHER GROUT SPECIFICATIONS <br /> COMMENTS: &MJ-SDA t EWL-}A WR ti\� 4IM5ME4 tL 1)6' OLrA :W—,'P 'YO c5d . <br /> TYPE OF WELL INSTALLATION TYPE r <br /> �/�w <br /> ❑,,,rrrMONiTORINr> HOLLOW STEM DIA OF BOREJiq.E _y\L Q tAIkTIPLE GSIrvGS O MX-T4LEVF.1 WE£.L CASING 01A' <br /> ���,,,.. <br /> tp EXLRACTiON p AIR HAMMERA)RIVEN CASING TQC"*SS TYPE OF CASING:O STEEL XPVC 0 OTHER <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUP SEAL TREMIE TYPE TO BE USED[)AUGERS[)HOSE <br /> p APR SPARG VOZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PLWED:❑Yes XNO (ROTE:MAXIMUM FREE-FALL DEPTH IS 3O') <br /> ❑SOIL SORING ❑RAND AUGER GROUT SPECIFICATIONS <br /> I I <br /> [3nn <br /> OTHER ❑OTHER. APPROX,SMNG DEPTH .GOCC �A 0 )jBOLTED TRAFFIC BOX OR D STOVE PIPE <br /> CONOLCTOR CASING PROPOSED (G YEa.PR rpewummnm+vnnv annual <br /> COMMENTS' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby DsroTy that I haw pmpamd Phis appikativn and that the worlr WIN be done I lecordsnea with San Joaquin County Ordhrancea,Ru4e and <br /> Reyuiaticas,mal 11 applies blJq G ornia Laws. i ('� 1 <br /> Signed `Pfi "-z- -.-. TroeM.onWanY _.�fA GAS UCP JO�VtT� <br /> Pant Name Datk(��_�.. <br /> DE/PART ENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADORESS: 6 F3 7- GL/• � ��_� y ST`�✓ <br /> WORK PLAN DATED: -o <br /> APPLICATION ACCEPTED BY CATEy' REA O p <br /> GROUT INSPECTION BY N R'Zt •Z'� FINAL INSPECTION BY (�(� TE 'PiG'4o <br /> DESTRUCTIOrl INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY AID i FAC a <br /> PE CODES .FEE INFO AMT REMITTED CHEGKi RECV'D ErY DATE PERMITlSERV)CE i INVOICE <br /> 29.0 <br /> 2.040 R 2-'be <br /> G57_ -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCFPArCHMENTDOC_ <br /> enc 290, +,9A1 M'E6) �ufll uli AR <br /> FILE copy <br />