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SANS JOA+QUIN COUNTY <br /> z• ENVIRONMENTAL HEALTH DEPARTMEN7 LOP <br /> �c SITE MITIGATION <br /> 800 East Main Street,Stod*in,CA 95=4029 UNIT IV _ <br /> -. Telephone:(2091468.3454 Fax'(209)4BB-3433 Web:ww*,4jRar.oM/ehd <br /> •�,?is <br /> WELL $ BORING PERMIT APPL)CATI0N <br /> FOR tNELLSAN1)BORINGS US ELY FOR CONTAMINAW JNVESTfGATIONIS AND(REMEDIATION <br /> fib FUNDABLE PERMIT IXPiRES 1 YEAR FROM DATE ISSUED <br /> ADpliU'dM ie hereby mast;to San JOaQL'iP County fora permit r0 Cor;Wuct andlor Install Ute work dascrffied. This application is made In cwptisnce vAlh Son <br /> Joaquin Courq OW.'elopmontTbe,Chaphar 9sT 715.3,and the Standards of the Sart Joaquin Couhty Envirormental Hee3th Oepartmeni, <br /> SIOe Location do�O F1r�i e Iy :ro5a st t�6t _ ta:: t st C.2y c Zip 5 3 AP IN 1'3 5'CaS 06 <br /> Property <br /> AOfkess 1101 10, (!ct pry S cx 1�. _ p r1 jZ0 S Phone <br /> C 57 CantraGta C_� 5" il Addros�.. 'L.Pr�1 Vic+ . ,city`_n n. i£�s�t L ic�� 3��ph ��-S -to4 � <br /> ComuttanbrSubCntr )C6ece 11(oap 1 i� a# City_ �cciw.tiaR llc r _Ft+orte O%k 7T<-jY <br /> T,ip JL PharteO IS(e <br /> GM Coordinates:K Y <br /> CONSTRUCTION WORK TO BE PERFORMIgID: <br /> [a KEW VVr_LUBORWG tCPT,efaPRDSE ti'�cpLwr_h,HANO-ALiGER,on+IX) <br /> ❑SOIL BORING Ips _ <br /> ❑VIfEt.L Je3, <br /> ❑OT}11=R IDs <br /> TYQFAI OFMI_1jRORING_ IMSTALLAIlOM DTP_ C0PJMU9Tf0N SpfiCrFl,ATMK$ <br /> ��MQNfTOf?INv ❑NOL'AiNSTEM DIA.OF EICR21C&E Q 1AULTi PLE CASING$U MULTI•LEYa_VdELL CA5INCi D!A: <br /> _-E EXTRACTION Yapouwairr El I AMIVIERMRJVSN wgSINGTHICW4M TYPEOFC $W4G; ©STE3EL 0PYC Q 0T4,'_:R <br /> __n SCJ!VAPOR PNC ❑MUD RaTAF?Y DEPTH OE GROUP SEAT _TRr7AlE TYPE TO EE LG6D: ❑AUGER$Q HOSE ❑PIPE <br /> 2.AL e30MNG Ll PilSM POINT*N CAT) GROUT SEAL PUMPED;❑Yes❑ta0{K%AX16 N f4tE FALL DEPTH*30 F-,) <br /> INJECTION r_r.ti gps [m>wl D WE AUGER G iCUTSPECIFTCA710NS <br /> r-OTHER ❑OTHER; APPROX.BOF.IWDEPTM ❑BOLTFDTRAFFICBOX OR L::S GVE P)PE <br /> COMMENTS; <br /> CONDUCTCR GASWG❑No❑Yw,Qmng Ora: Pte: A.&m D*__ <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> pkSTRtjCjMH►ORKTOEEPEREEBAIJED: t]E'UMeTIONMEErROD-(c4ECKALL THAIAny) <br /> >tOF11PLE(S) HE C£STnYEG OVF3t$GREDIAMETER Lf1?,_iNCHESTODemoFAFr <br /> WELL IDs: �e� a e 1. P-A Ala We RESSURE GROUT TODEFMOF '35- FF BELOW SURFACE <br /> GRttJT SPEI;IFIGATIONSEXPLOSrW S FROM To_FT o aIOW SURFACE <br /> TREMIE TYPE Tp 8F U$FD: AUf ERS HOSE PIPE ❑MusfiRoom CAP AT(9 FT)_FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERIIIET ISSU NANA CE)FOR INS PEC��APPO�NTS �""' <br /> I hambp panty that I have prepamd this application and that the work will be done In mmordanae with San Joaquin County Ordirmoc",Rulax and <br /> Rsgmiattoltt,�,od al applicaW f3fOmia UWL <br /> $gtlet7 ►..r `. lk i— j�II2 .OR1pBnr -+ yr w,� 1%- f - c"' <br /> a I• Q1,1 ;1,r1� <br /> Pratt Name -7 8I_,rDate 5 'i <br /> DEPARTMENT WSP ONLY <br /> SITE MAP IN UNIT IV NILE-SITE ADDRESS <br /> VPADRK PLAN DATED L(� <br /> APPLICATIONACCEP71EDBY _ _ 0ATEISS�� D AREAqqj <br /> G?nVT WSPECTION BY RNAl.I SPEGTON BY I Grp <br /> �i�- DATE CJ <br /> iff <br /> DaTK.Y;_7i0N 114SPECTION BY DATE <br /> CC M?JENT8=NDITIONB: - <br /> •4CCDUNTVG ONLY: Ait7 V Fr1C$ <br /> PE CO= FEE INFO AUT REYITTEO CHECK W. RECVD BY DALTE $E B KvO1cE <br /> --- POEM EST PRO <br /> $Tzx2o -q4 <br /> PR# o��slr <br /> G-57UTO WAIVER C-57 LETTER OF AUTHORIZATION Tp SIGN PERW7 ENCROACtWQKT D4C•�_ <br /> EHO 2$-X ahIWTD <br />