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{fur • San Joaquin County • <br /> ;:;Iixr,I <br /> Environmental Health Department SITE <br /> 304 Fast Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)4%3449 Fax:(209)468-3433 Web:www.s}gov.org/ehd UNIT (V <br /> A' <br /> Well Permit Application <br /> 1101414MIKINOABLE POINIR EWMa 1 YEAR FWW DAT!OMED <br /> Apok0w k hereby made to San Joaquin Cousy for a own*to contract wwor Mdat am work Ceadlbed. Thh appks0w H made In <br /> Joaquin Cou 4y DmAop�rna i Tau,Ch&PW 8-1116.3 rid fin ka <br /> SUuwwds aP an Joaquin OMW ErnsernW Huth L <br /> O'Oww'pnmmpilenoe with San <br /> WELL Loam" +intl ue Croom y,,aa, Ripon 05368 A on, <br /> M7, cMe &ma 30063 Balnbrd< G� colon DNm K`�!3 <br /> c aY co uadw — <br /> cily ,3, <br /> CasoRma I Sub CnM EOM Addrw WO Baker Street Cly Costa Me"� (714)662-2750 <br /> IIS Cowdrat":X Y ,TOMXPAP Raps S°oyp�- <br /> tTD BE PatFtw�r w <br /> X NEW WELL I BORING (CPT.CEOPROSE.HYDROPUNCH,MAND-AUGER,DTHERO <br /> X SOIL BORING 0 DESTReJCT1pN (rJ,aoea tyya t <br /> 0 WELL* 8 OVER-BORE. DIAMETER <br /> •Oth" 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMIMETNT5 A <br /> 1Flom so attached may a tatw, <br /> TYPE OFrrEL <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREFIOIl;,-, �• 0 MIM.TIPLE CASINGS 0 MULTI-LEVEL WELL CASING DLl: <br /> 0 EXTRACTION 0 AIR HAMMERIORIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: _,- <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE!OZONE X PUSH POINT(GP or CPr)GROUT SEAL PUMPED; 0 Ym 0 No (NOTE:MAXIMUM FREE-FALL DEPTH 13 301) <br /> X SOIL BORING 8KANO AUGER GROUT SPECIFICATIONS <br /> 0 OTHER' n OTHER APPROX,SOBW DEPTH Varity,orae table -j BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONMENTa: wAlPROPOSED M YEE.OttUdd9Cdions in oommad"Goon) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORIONO HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I harsby c6li tyr that 1 have prepared this application and that the work will be done M accordance wit San Joaquin <br /> County Ordinances,Rules and Regulations,and all appikable California Stab Lama, <br /> Print <br /> DEPARTMENT USE ONLY � <br /> SITE MAP IN UNI7IY FILE ADD SS: <br /> WORK PLAN DATED- L -2-3 I C) I t <br /> AMlo+a0n A0 By*— -- ,i-", Date Issued <br /> G10�Ineosalen�' Lam- --.,LU <br /> Dole —j leePecsort By — — ay— <br /> DaaludlenlropadbnBre -- <br /> commorn;I CONDITIONS, _ <br /> PPECOD" <br /> NTING ONLY: AID* FACE <br /> FEE INFO AaK>UNT Ra'MITTW NNPURM I ERVICIOR@W1ESTO INVOICE� SR# 5o5�� <br /> C-57_ WC_=WAIVER_ C-57 Letter of Authoritation to sigh permit Encroochmtnt doc <br /> PJND 2?OLODI <br /> 62Zp# <br />