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JUN - 24 - 0Z 11 : 04 AM BFT- - INC - 909 9_ £29 9556 p , 02
<br /> 06/ 24 / 2033 05 : 41 2L FIFTH FLOOR PA13E X02
<br /> WELL PERMIT APPLICATION FORM SITE
<br /> SAN JOAQUIN COUNTY MITIGATION
<br /> - UNIT IV
<br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD)
<br /> 304 E . Weber, Thirst Floor, Stockton , CA., 95202
<br /> j (200) 4663446
<br /> t19�$EEI�SBL�P r+�NE_ 1PIhL1� Y�A3EB41�li MikaUlif,3
<br /> Appllwliun is hereby made to San Joaquin County for a penult to Cenelruet a1Ivv:natatl t work descrlbad. Thls appuwiw is made In oompmvw wtA Sen
<br /> J000.1 County DevNopment 'npe, Cna�n}nta' 9./I11 ' S,a eno the Standards of San Jobwn Counhy Environmental Healtl Department.
<br /> 1425 �df fgodal "r (31L�, T Aaeauara
<br /> WELL Loca!lonCroaa StraatC� ity ._._1iip��Pnrrfl#-�
<br /> IRtOPER1Y Owner �fA 7-;+� _Addmsn=7I�Qh InlEr Cl , �Ipq1710 Phonae ,5117' $!
<br /> C-a7Cntttrxtaor S l�i _��AUdraei. tlgq��Lp,(,�eIIO__ � pGf�y,./ fjiP1S}173UCY {�7461Ph�naa 0 7 z - _272.
<br /> Consuhanhf5l0 CCntraetef �, _F�,1�. , . ddrC67J1.:i6, rn��l,!•C7^.... C[Y-. ..Uvft Phon&Y760 rr72.,
<br /> i
<br /> 015 Coordinates: X ,,,,__�, Y , Townmty'pRange SeeUnn�_;
<br /> 4(qg RIN
<br /> ERI '
<br /> LL f� 0 T, 3E0PROBE, HYDROPUNOH, HAND-AUGER, OTHER') ODESTRUCTION (Eheo6a d�ypee below)
<br /> q 901E 6ORIN # �,_ d OVER-6C1RE
<br /> PA21$UAk ai0UT1
<br /> •OIVwr;,�_„__ .._,—, � G+out Spec111caGp�r: p ro �a . N.�GatWI� l[.N "7. '_ta'1_A'&f
<br /> COMMENTS:
<br /> TYpE Of WELL LATI 7Y-�� CON(LkUI BVEF K:A
<br /> 'Y}ONITOR�NG OLLOW STEM DIA, OF BOREHOLE MULTIPLE CASINGS? D YESNC WPLL CASINfIOIA, Za/
<br /> a EXTRACTION a AIRHAMMERIGRIVEN CAMI'IGTHIChINESS TYPEOaCASINO; 0 $7tE4 xPVC OCTt•Fk:
<br /> D VAPOR 2 MUD ROTARY DEPTH OF GROUT SE 2• _ __ TREMIE TYPE TO 5E U8E0. *UDER6 D M08E
<br /> Q AIR 6PARCF p PU5H POINT GROUT SEA:. PUMPED : 0 Yes JfNis (NOTE; MAXIMUM FRES ,,FAL DEPTH 18 0t)
<br /> d SOIL BORA 13 0HAND ALIOER GROUT SPECTFIc:ATION6� mclu' . parf CCI,dJ /A/- PJA
<br /> D OTIIGR;.__. ._ .__. _._q OYHFR APPROX BORING DEPYN J2 7*CLTED'TRAFF1CbDx. or OSTCPIE PIPE
<br /> CONDUCTOn CAGING PROPOSED?_ __ ( If YE9 IPol epeaAcatlona nore)�_,
<br /> ' •COMMENTS: � _
<br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS.
<br /> CALL THE UNIT IV INSPECTOR 46 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS.
<br /> I hereby certify that I have prepared thle appliCatlon and that the work will be done In agcordance with San Joaquin
<br /> County Ordinanc , Rules and pulatlDna, and all appilCablo Californla State�aws,
<br /> &pried a—„ „� _Tlae/Campany^,
<br /> Prnt Name_,, _para I;r�Z D,pj
<br /> I
<br /> TME� T
<br /> SITE MAP IN UNIT IV FILE, ADDRESS ; 4 Z !g L4 rc C e, i I ('.A
<br /> WORK PLAN DATED:
<br /> enlluaonAcactatlBY�yig � Dau, Teepee� une �S2G (13 A,oa., [�
<br /> Brawl Inspecdon By�iCr�AYil .G.CQY -- --1 _,DaW L 42 G!., pinat lnapadbn SY ,YJa ,' Lr y lata G G 3
<br /> DaahaClton Ire ctlon B Date r
<br /> COMMENTS / CONDITIONS, S rnon
<br /> ACCOUNTING ONLY: AION
<br /> PECODEdS FEEINFO AMOUNTRENaTTED CHEOK9 RRC
<br /> 'p BY DATE PERMRISERYIOl REQU[ST aI INVOICE
<br /> 35019, 90 � $ , U0 --� 34
<br /> C-57. WC_-WATV6R, C-57 Loftar of Authorizotion to Sign partnit_ Eneroachrnenf doe____ 1/25/02
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