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11' IJ 1/�I:JYIV l t.l•J..I �.LI-1 I 1 L _Lf'1J["11 Y 1 lJl'1 _r -cur.cuYL'J�Uju <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE II <br /> 600 East Main Street, Stockton,CA 95202-3029 MITIGATION �1 <br /> 1, horse,(209)468-3449 Fax:(209)468-3433 Web:WWW-919-010ehd UNIT IV I <br /> WELL PERMIT APPLICATION <br /> NOV 1 2 2008 r40N EFUt�DAQLE PERMIT EXF'1RES 1 YEAR FR DATE SSIJED <br /> �n Cou►tY for a pertriit to construct and'or irat0 tl*mdr d0f`Ibcd_ This application i°made in compNarx a with San <br /> As�ors p70-,2& I <br /> Joaq &,rlrapber 9-1115.3 and the StRandarFds of San lo�quin Cnu �Qq �atcel# <br /> • Y Cross Street -l.(,►'L1C>f� �Seo G <br /> pmzip <br /> LOratlon K// P/lo1%kT, 5 ` 7 1 L y Phone*3 <br /> Party% r E� u1ER"►cv cd SEQuaA AKw/ Ctry tr oRt '2Zjp 91— <br /> Owner 5AJAEL �J S Agdress 1 S3 0 <br /> 020U1t-oF 777OD��$OD-5Sy_ <br /> �o•$ G o7 3 Gftr -- sic <br /> c.a�contaeetor Adores <br /> �y ��— <br /> ComultBntrsub Cntr '._yu(4ud&" <br /> ►r Lor)(0 q Rama SeCUon <br /> LATGIS Coordinates:* 37• - y, -�.�I.Z! TownstnD I <br /> RK To BE PERFORMED: 0 PESTRUC-noN(CHOOsE T aE ow! <br /> NEW yy@>yBgWNG(CPT. QIyR hYDROPUNCH,I."D ntIGER,OTWPW), 0 OVEF2-BORE DIAMETER <br /> jgsm.BORING* Lf �� / ❑PROLrr S E GROUT <br /> WELL* (/'(pOH SPl CIFICATIONS <br /> ❑-OTHER <br /> COMMENT`': <br /> TYPE OF YVEI 1. IN57ALLAT10t1 CONSTRUCTIQN 8PEG_r}F W <br /> []MONITORING ❑HOLLOW 9TE1� DIA OF BOREHOLE �� ❑M.ucnpa CASINGS O uULTI-LEVEL 'vJELl CASING Qt1ti <br /> AIR Kkmm RNRrVEN GAFANG THICKNESS_ <br /> TYPE OF CASING:❑STEEL I]PVC OTHfR <br /> Q EJCTRACTlON <br /> 0 VAPOR Q MUD ROTARY _pEPT'tl OF GROUT SEAL TRETuIE TYPE TO @6 USEO E]Atifi'ciS HOSE <br /> PUSH POI U� OR In—GROUV SEAL PUTAPED:0 Y-.)&.MOS Mk�UMUM FREE-FALL DEPTH i8 30) <br /> C3 AIR uPARGE,'OZONE <br /> `SOIL BORING ❑HAND PULER GROUT 3GECIFICATION-S <br /> G DEPTH ❑BOLTED TRAFFIC BOX OR ❑S10VE <br /> AQPROX BORN J YFS.iR�edflok.,%e in mmnal[ o�) <br /> ❑OTHER O OTHER: CONDmToR Crs+r7G PROP=a <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREIEMENT OR ENCROACHMENT PERhIrrS <br /> 4a WORKING HRS NOTICE REQUIRED FOR(}y,SPECTIONS <br /> 1 hereby oardfy fftd <br /> I tla+re this apPflcaUai srrd mat thQ work will 6e done 1 a:c .-ce wim San Jaagtlin County OrcFinancs- Rules and <br /> RASfukations, II ap b Calttornia laws. _ <br /> TlWcompany <br /> Print Name <br /> �j DEP �Tl <br /> ONLY <br /> Z9 <br /> SITF MAP IN tlNrr IV FILE,ADDRE$$: �� f' <br /> WORK PLAN DATA: <br /> AREA <br /> APPLICATION ACCEPTED BY 3 , a9 <br /> GROUT INSPECTION BY <br /> FR�1-INSPECTION BY "~ DATE <br /> DESTRUCTION INSPECTION BY- DATE <br /> COMMEHTWOONDMcas <br /> ACCOUNTING ONLY: AID* FAC# <br /> PE GQDES FEE INFQ AW PJUAITTED <br /> CHECK 0 RECV'D BY DATE pERmITJSERVVGE* INVaCE <br /> G-57 WC -WAIVER <br /> G5/tfTTER O AuMORIZATION TO SIGN PERM ENCROACHMENT DOC <br /> YJE�L PSRIIR APP <br /> F_t10 2B.t11 41151Qr(� <br /> FILE COPY <br />