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q0/Lb/YggC) lb:q7 7tOJlOt7.7t7t V"IRG1717 LRiLLlll\7 ��� �- <br /> t'AY-26-2805 1537 P.02/03 <br /> San Joaquin County <br /> Environmental,Hetlth Department SITE <br /> 304 East Weba Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> • - (209)468-3444 F=(209)468-3433 Web:www.sjgov,orglchd UNIT IV <br /> Well Permit Application <br /> NON.FtVUNaA"PERNdT ESS 1 YNR FROM DATE ISSUED <br /> I 1vr s Is aenflnld and/or irlsteH tha vretk d,teortEad. This a Mallon It made in eompfianoe wflh San <br /> In haltbY mads M taan Jooquin Golr+h 1 +8 <br /> ,�gvin County pevSopment'Tloo.duplex 9.111115.33/ana the Stoodarda ot3an JmWn Courdy ErnAro<+mentsl Has DePanment. <br /> YVB.L LoeaMon a CSL I'T Oros Street Chy P Paroa1M Attessors DOS- <br /> Lf L <br /> PROr AddteseC CltyZ)pPharte5 <br /> Owner <br /> 0.97 <br /> Col rnt I sub carL7— <br /> GM <br /> iii Cron, l�. P �9 —t S <br /> Covdln"M:x Y .Toweshlp RwVe <br /> pseabork- <br /> NM WELL I SMNG (CFT.GEORME,HYDRoPUNCM.wwoawoER.O"IER-) VDE9TRUCTION (ct,oe..typo below) <br /> q SOIL BORING s01AM <br /> ** ETER- <br /> ROMRE GROUT <br /> a GROUT SPECIFICATIONS� � <br /> COMMENTS.— <br /> MM OF <br /> Ih2r&&tIlOy c oN 3PCIM&T�Ns <br /> a HOLLOW STEM DUI,OF BonmoLE�. _ a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> Q DcrRAcnON Q AIR HAMMERVAIV gN CASING THICKN61✓1TYPE OF CASING: Q STEEL Q PVC a OTHER:-_,_ <br /> 11 VAPOR a MUD ROTARY DP_PTH OF GROUT SEAL,_ _ TREMLE TYPE TO BE USED: p AUGERS a HOSE <br /> a APR SPAROd OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 11 Yes Q No (NOTE: MAXIMUM FREIE-FALL DEPTH IS 3W) <br /> a SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS - <br /> Q OT}�R::,0 OTHFA APt'ROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASINO PROPOSED_(F YES,Mat speStieatlons In comm m section) <br /> COMMEIM- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCR2gkCHMENT PERMITS. <br /> a WORKINO HOURS NOTICE RECWIRED FOR INSPECTIONS. <br /> I c wft d*I thaw prep)) this appiicadon and ttlat ttw work will be done in accordance with Ben Joaquin <br /> Cot Ord and ule0one,and all applicable Caliiomia State UMS. <br /> sed M r�de/Compeny 6�!!7 .br <br /> Print Name , Date P 7L?A= <br /> DEPARTMENT USE ONLY <br /> BITE MAP IN UNIT IV FILE,ADDRSSE; <br /> WORK PLAN DATE:t� <br /> ZoD Gam• / / <br /> APPb"Aid SyDeas <br /> Dais nal Inspedon By Dale <br /> eswc k"Po—s"BY Cam <br /> ACCOUNTING ONLY: AIC! FACS <br /> PE CODES FEE INFO AMOUWr REMITTED CMWK tt RECD BY GATE PERMIT 16aRMCE REQUEST/ INVOICE <br /> 5SD& aS/2 tom- / gr <br /> -SRODDS ��Z <br /> C-57— WG -WAIVER C-57 Letter o,"Authorima Von to sign permitEncrooehmatt doe_ <br /> END29-m-iml <br />