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11/17/2005 11:39 2094681,_, EHD <br />PAGE 02 <br />FILE COPY <br /> <br />San Joaquin Countir RECSISIT-E Environmental Health Department <br />304 East Weber MCITUe. 3rei Flocr, Stnekion, CA 95202 v MITIGATION <br />(209) 468-3449 Fax (209) 468-3433 Web: www-sigovxmeclio <br />ENVIRONMENT44ZALTH <br />/ e ? <br />UNIT IV <br />, NU <br />Well Permit Application <br />PEAMITASERVICES <br />MONREFUNDADLE POW WIRE& I YEAR MOM DATE ISSUED <br />Apprp:caion 4 hyrany mole to Son Joetnln Canty far a permit ta conebuct undior relai Inn lAuli describet Thin appkition op ma* in complance **titian <br />joaco county p.m.pi -nu mamba.. g-111S.S iind the Stem** of Don inotttin Thirty EtTiefronmentel Health DeInerrIalt 091-X30 - II- <br />Ameettan,4061.•100-1) I <br />WELL tscallon I I II .2. ,..,k1jile St tit fee- crim 86130 R:(3r5br \ ti coil Loci ! zip 675;00 pap*/ 65'3 -,430- 1 11 <br />cr_e_6,rvorr"s -/- clo tALe I IS 4 rge &AK 1 <br />iter3Torttn—Prittrleoe ml-ess ViCIS IL qestla -f-. city_EILC.W.X_AP32E9trino s 51 '137— 3°56" <br />C47 Otritradnr <br />I PILAU. Photos* /Al 4-05' i (t <br /> ,.-11.02Y----/-Alt Phanell <br />caa • x6,3"a/55,..2.1L.y .7 /0 7 6/5 To.mehip T 21 Raror,_14.7 seeder <br />wORKTOPEPpEoRiED <br />a NEW WELL I BORING (CPT, GEOPROBE, I-D'OROPUNCH, HAND-AUGER, OTHER" a DESTRUCTION (Omen type eesow) <br />16* Bonlreo I JQ ' eWU.LS I <br />INVER-SCRS. olAkeEniR <br />D PRESSURE GROUT <br />13 'Mar . GROUT smcincxnctts <br />COMMENTS., 50A. .1"xlviom o-fk.o k.S kv-t- ctslot. ------e'.(7)14451bA- <br />1 Typc.of "mi., !Ktei.LatOrem eqqrtutrom ""17419.65 <br />1040NITORING WI-IOU-OW STEM D1A. OF DOREFIOLP,_& 1) MULTIPLE CASINGS 0 MULTHLEVEL Wa.L CASING DL___ <br />O EXTRACTION UMt #-{AKIAERtoRivEN CASING THict(NESS ch 80 'TYPE OF C./0NQ Cl STEEL "PVC 11 OTHER <br />11VAPOR 13 MUD ROTARY DEPTH OF GROUT IRENE rem TO BE USED: 11 AUGERS D HOSE <br />a AIR SPAR= GZOIwW (1 PUSH PONT (GP orCPT) GROUT SF-P4. purom a Yes (NOTE MUM A1.1- DEPTH IS 301 <br />a SOIL BORING D HAND AUGER GROUT SPECIFICA <br />11 OTHER: 13 OTI-ER APPROK BORING DEPTH )00 v4 11 Tem TRAFFIC BOX to xtvrovER.E(W) <br />1 COM,UCTOR CASING POSED IN1 0 (if YES, Mt npociandons In ecawnenlandion) <br />cowagam3: Silf (le X_ ill i ;,' v GJL amitArci--.4 .t„......k........_10 — /19 • A .• la • A1C.1*--• <br />"4f )( 90 04-. 6r06 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />41 WORKING HOURS NOTICE REDUIRF-D FOR INSPECTIONS. , <br />ADPfIcatiori Axe:pked By <br />Gm* Inspection By <br />DesIxtrt:on Inspection <br />Alfa ..m.-......--;;Naste• onr 1 i'> F3 Inspection By <br />I hereby certify <br />County Ord <br />8161114id <br />Piint Name <br />ths appllctIon and that the weit will be dorue Its accorda with San Joaquin <br />egu na all applicable CalEtarnIe State 17evia. <br />z‹:3X2;•P -;zL <br />DEPARTSENT US ONLY <br />arm MAP IN UNIT IV FILE, At157,7 <br />PLAN DATED: <br />/1 - / <br />111,21-411ff .* (2 <br />BY <br />campus commas*: Getrks), 12d tin s -VC,s1 'Ill tYrtzi4o <br />AMOUNTING ONLY: I NM FAIN' <br />_ r4)-ybq tv...,7=-P-L-40.--,‘2 <br />PE CODES FEE *IF° emotarr klift11111 CHECK tr RECO BY DATE INVOICE PERMIT 1 MIME REQUEST* <br />aq o7 '3 9 _ 'P_ 2 9 to 7 -i'lc(.)— SRI <br />C-57 WC -WAIVER_ C-57 Leter o uthariaition to sip permit_ Encroachment din <br />ata 24 -09 .00j <br />6122104 <br />Nov-17-no5 12:3GPM FAX:20946E3433 <br />ID:MWH <br /> <br />PAGE:003 R=9G% <br />2/2'd 2D7289t7602:01 2016b269T6 HMW:Wald 9T:21 S002-LT-OON