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04/04/206 ',13:04 20946034'0 FI=TH FL.nOR • "NLtl °` <br /> WELL PERMIT APPLICATION FOF.M SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMCNTAL HEALTH DEPARTMENT (E HD) <br /> 304 E.Webor,Third Floor, Stockton, CA., 95.t02 <br /> (209)468-3"9 <br /> NON tUr1DA LELE PER6a t��FROM.t�I�i OEM <br /> TI <br /> AppncaliOn I4 hereby mad to SOm J roPD P Perm" of Sunt Joaquin County EimAto the work R�rpnmarAal H�Dea rbnenlda In compl2nce aftR Sar. <br /> Ass+ sire <br /> doacrin county Dene aPn+Ca rat 1�Du0� Q0 Crpss 9ewt <br /> � Cly __ gej JJ�ParcolM, <br /> WBLL Loeatbn 38.6 2-71 <br /> PROPERTY <br /> PROPERTY O VW,, r'rs- '�IY�U.1Yp,- Add'wi rPO' Sir 1 d�V ,��LP���(�{�y��y�� �,p.2�r1'6�>l <br /> lI LiW�.,fl'tIm0 ? <br /> Cdt Conbactoirge v irl 7�C�,.4dWeea <br /> •IW Uak-U rdLlce Phondr stc 63L $St� <br /> Corrpultant LSuLCOPvaMnC <br /> ^ `np2an�/Or Address 1ThoPrv.du.ta..e. aty <br /> .Y ,Towndllp _Pa+sae- _Secvpn-___� <br /> GIs Coprdlnatee:%`_ <br /> 70 g p R ORMED� I]DESTRUCTION(thooae typabe)ow) <br /> eW W ELL 160RING(CPt�GEOPR08E,HYDROPUNCH,HANDAUGER,OTHER p UVER,9-- <br /> Q SOIL BORING ^ O PRESSURE GOUT <br /> _Grout Spei icabone: <br /> -L- <br /> contrneN��� I, <br /> ME OF WE <br /> CONBTRIt['*rtu cvE(y8 r� <br /> PONtTOWNG ICU OVJ STEM DIA.OF aORLROLE�MULTIPLE CAEIN3 rl YES NOC `WyELL CARING DL:_ <br /> 0 PX(FACTION 0 AIR HAMMERlDRIVEN CASINGTHICIWHSSP�TYP£OFFCC�tE �E TO BE USED: 0 O GERSR. 0 H09F� <br /> d VAPOR p MUD ROTARY DEPTH OF GROUT S <br /> (NOT A OPMUM FA E FAL4 De NIS 30`} <br /> D AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: Q Yea O No lI-/ Q'�'1Ta'"r�r t <br /> HA14DAWFR GRCUr SPFCIFICATIONB� _C-C-t^^e'� )LTEO rFtAFFIG 30K OSTOVE PIPE <br /> Q 9O1_6CIRIHG APPROX.BORING OipTh -15f) r --� <br /> Q p'�HER: 0 0TH&R <br /> CONDJCTCR CASING PROPOSED? _(itYis,I'ut spedfretV,ns here): <br /> -COMMENTS:_.---- — — <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FORA_L REtlWRE[)INSPECTIONS. <br /> I herehy certify that I have prepared this application and that the work will be dom in acoardanm with San Joaquin <br /> County Ordin R es an t Ulatio ,and all applicable GRINorNa State Lal is. - <br /> nvey 2/- <br /> �� Tire/C:ompanY E'G L <br /> _�L cy�rs r) <br /> Prin:Yan» DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE.ADDR <br /> WORK PLAN DATED:__ — 2 �� 9 y <br /> Dale Issuai `{��b— <br /> Appiication A=*pted 8Y Cate _ Fnal Inspe'ft n by- Dale_. <br /> Grout Inspedon BY n... _Q 0 .y <br /> Dtmwctlov irwedw 8 _ <br /> cOMNENTOiCONDITIONS: --i--- <br /> 1 0.CCOUNTINO <br /> AID# Eryc —_ <br /> v_ <br /> GYLV: PI7p7AT,-SERACr <br /> REpUEBT PReC'D iY DATE <br /> pe CUDS8 FEE eif0 AMOUNT REMRE❑ CHECKR y t f3 <br /> 'jcj 14 3033 1125 <br /> /O2 <br /> C-57_ WC-WAIVER— C-57 Letter of Authorization tO S19nPermit_ rmchmpnt dot— <br /> Z© <br /> 39bd I53 5LE899E80h 5h :8I NOVOT,W <br />