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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEA(-Tl DEPARTMENT LOP <br /> -3029 SITE MITIGATION <br /> F. 6roo Eag M4n Street &ocktai,CA 95W2 <br /> UNIT IV <br /> T99'bphon,9--,(209) 468-3147 Fax- 1209) 468-3433 Web- vvwWssI-q0v-0Ilqleh <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WIELLSAM0 WRINGS USS!FOR CONTAMIkNff IWESPGA711,oNS AmnRJ13,0-F-Ownax <br /> NON-REFUNUABLE PERMIT-EXMIRES I VEAR FROM DATE 4S'S111ED <br /> Applicafm is hereW made to San Jwaqdim Courty fw a penuffi to cansitucl amd/w bvAal 11hewaii(dermaribed. r-his alppicatiionls umde Ara cor, mFdh San, <br /> Jmaqtim County DievdmpmerA Title,Ctugder 9-1115A an,if the Stan.dards al the Sap im qLom County Emvirkawrmn.120 Meallgh Depwitnemi. <br /> Site Location 2M his Rowl Cm3ss sheel 99 FmnWe Road 00 %galkton AP-25205 APM _J?g- 1 0-04 <br /> Pro eft <br /> 0wfw- Juan m,mgm Address CRY 'ap-2213---,'Florone mq9is <br /> C37C*nhraotar SAI VMjAbamdanmerzj Atdress 192458saVvDr�wje,S&9eA City Sacramefrift -tic 83 59 Phone. <br /> ANamost <br /> constalamusubcntr mcn Addraw 837 Shaw Road fAv slodkimm Uic 138DU7 Phame 209-467-9005 <br /> Bmable PartyAdvanow a37 Shaw Road cft Siam -Z-lp X95Fhmie 2DR-167-1006 <br /> GIs Coonfinates:X3'7 WrI3917-9 Y -1-21- 239471AP799F <br /> CONSTRUCTION WORK TO BE PERFORMEO: <br /> [3 NEW WELLMMNG MPr.GEOMME.HlYER0RU=K HAMDAUGER,ORIE14 <br /> 0 SOIL BORING Ms <br /> 0 WEUL ODS <br /> (I OTHER IDs <br /> TYPE a 0 OF MuismNG INSTAULATM TYPE CCIOISTRUCTION SPECIPICAMONS <br /> 13"OlLcm STEM -DIA.101=SOREMMAffiE MULIV11E CASUGS U MULTREYBL WSUL CASM DA: <br /> EXTRACTION:VaMcdVgaw 0 HANNIERMRMBN Ckswr.m CNNESS TMEOFOASMS: CISMBL OPVC 0 OTHSR- <br /> -0 SOL VAPOR PROBE J3 ant-M ROTmRv DEPTH OF GROUT SEAL TYPE TO BE USED: 1[3 AUGERS El INOSE J3 IRIPE <br /> _CI SOIL BDRMG 0 Pilm P03NT(Gm CPT) GROUT SEAL FUl MFEQ:131Ycs 13-No MANNUM FREE FAM DEPTH ISM FT¢ <br /> _J[3 MECTIONtim El IHAND AVI GER GROUT SPECIFICATnOIV� <br /> cl 0 R "ROX.'&YDF4M DEFITi A C3B0lrEDTRAFRlC8QX GR q3ST-OVEIRIPIE <br /> COMMCTIR CASSMS�No[I Yes:Cagwm'Dia: C-mlaing Dqgoh: 0aftaVis: <br /> COMMENTS-, <br /> NOTE, OFFSITE WELLS&8OFJNGS REQUIRE ACCESS GREEMENTS OR ENCROACHMM PERMITS <br /> DESTRUcinom VV0FJ(TO HE PERFORMED. m'cnQN ATEMM 9)HIPOKAUL THATARPLn <br /> #tWWF-Ai(sl Tia EE DEBT-IZOYED OVER-BOW DAVETER DF.20,9 imafm'm Imre-OF 3 rr <br /> VVELL I:Ds:: PRESSURE G RC MT DEPT+4 c f 78 IFT OMM SM-FAVE <br /> GROUT SPEOFKATms TVM Ifil Heal C&iWn-t <br /> I <br /> TREMIE TYPE TO HE MM.0 AUGERS INice DPIPE MUSHROQU CAP ATt3M )FT BPl-4DWSUWA0E <br /> CMIMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT IS SUFFICE)FOR INSPEcTioN APPOINTMENT$ <br /> I hwi?bylcerft OmtF K22_lMb the wwk van be dwe im accombrme vom sm'*Oaqv�m cmmty ckdwsances,R%dras w4d <br /> m <br /> Regulaams,andyppftation and*?at <br /> 'rm-rAxinpamy Ptesident I Advanced GegEnykangwntal, lnr- <br /> Pmt Marra, Robed NA Date <br /> DEPARTMENT US:2 ONLY <br /> SITE MAP IN kMff TV FILE-SITE ADDRESS .2950 Lcv)"is 20gd Sto e.k <br /> WORK KM DATED <br /> APPUGA-nom P=EpTm By )&-+Or;& m AAr-the" DATE Ma9 3 za; AREA 14 S' <br /> GROUT INSPECTION BY FM NSPECTION BY DATE <br /> DESTRUC111ON INSPECMN BY DATE <br /> MENTSICONDITtOM: I)e-S+ro 2j-_&ff-S i te- M,0 Yi i f-a—r-, 22 ga we W -5' <br /> ACCOU14TING ONLY: AM 0 FAC 9 <br /> PE CODES FEE Mr-0 AUT RENITTM CHECK x RE-c v*0 By DATESFARME Re 0 INVOICE <br /> Ri---QUEST PRO <br /> 350Z 312sx 0 0 3 V� SR# PO(,44 10 <br /> ly RO 5 <br /> 3 6'0.3 376-Ad 3,75. OQ (3M% <br /> S- <br /> PR# <br /> C-57 vvc WAIVER t-S-f LETTER OF AUTHORIZATON TO StGN PERMIT EWROACHMtNT 00C <br /> EMN-01 OV13112 v4a.L PeRmir Ww- <br />