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KATION FM s�rE <br /> fERMIT ADPL MITIGATION <br /> WELL UNIT IV <br /> PHS-EHD) <br /> SAN JOADIUM COUNITIEA�H DMS ON l A 95202 <br /> ENVIRONMENTA H Floor, Stockton, C , <br /> 304 E.Weber, (2091469-3449 once with San <br /> 1 YEAR FROM DATE IS h sE application is made in COmp Division. <br /> R EXPIRES described. Environmental Health <br /> NON-REFUNDABLE PERM public Health Services, Assessor'$ <br /> for a permit to construct and/or instal^County Lp G l� parcel# 1 N-- <br /> made to San Joaquin County J <br /> Application is hereby ment Title,Chapter 9-t 115.3 and the Standards of San JoaqGib one# <br /> Joaquin County Develop Gross Street Zipj�Zir" � <br /> �Lzoc Ga city 1 7-�na� <br /> '� �� - Uc#Irr�'`' Phone# <br /> WELL Location rA Address -� <br /> 11 C�ryZ'p }}� Phone# <br /> PROPERTY Owner c �-Ip;n Lic# <br /> Ui,'u9 dress `a� p��City� <br /> o ` � l atJ Section�- -- <br /> C•5T Contractor PU' gg P V,�,�M � �dress� Range__��' <br /> Consultant Is b Contractor d-��'� Toy,nship�—� a below) <br /> Y�—�� p DESTRUCTION(choose <br /> 0 OVER-BORE <br /> GIS Coordinates:X------�� 0 PRESSURE GROUT <br /> HAND-AUGER.OTHER') <br /> WORK TO BE <br /> PERFORMED'. GEOPROBE.HYDROP�NCH. S <br /> EW W ELL/BORING(CPT, OIL BORING# Grout Specifications: <br /> �WELL# <br /> -Other: W ELL CASING DIAr�� <br /> COMMENTS: , ves oTHER:�— <br /> 0 <br /> CONSTRUCTION SPECIFI*ATI MULTIPLE CASINGS STEEL PVC 0 HOSE <br /> INSTALLATION TYPE TYPE OF CASING: O AUGERS 0 <br /> TYPE OF WELL -� E DIA.OF 80REHOLE 7REMIE TYPE TO BE USED: 0 <br /> 1]HOLLOW STEM CASING THICKNESS— I•,UOE REE-FALL DEPTH IS 30" <br /> U MONITORING H AIR HAMMEWDRIVEN ° (NOTE' MAX t�/ <br /> a EXTRACTION pEPTH OF GROUT SEAL �eses g ��� �Y / <br /> 13 MUD ROTARY GROUT SEAL PUMPED: [1 STOVE PTFE <br /> VAPOR �,pUSH POINT t BOLTED TRAFFIC BOX or <br /> 11 AIR SPARGE GROUT SPECIFICATIONS: <br /> HAND AUGER ,f YES,list specif��tions here):— <br /> •�'501L BORING APPROX.BORING DEPTH <br /> OTHER_ - CONDUCTOR CASING PROPOSED? <br /> OTHER:_�� <br /> ENCROACHMENT PERMITS. <br /> `COMMENT$: L REQUIRED INSPECTIONS. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AN <br /> 48 WORKING HOURS IN ADVANCE FOR AL <br /> oa <br /> CALL THE UNIT IV INSPECTOR <br /> Ilcation and that the work will to done in accordance with an <br /> that 1 have prepared this aPP and all applicable California State Laws. r <br /> I hereby aeRlfY and Regulations, 2 (o•L /5 <br /> County Ordinances,RU 'a TdlelCompanyy Q f <br /> Date <br /> Signed)(- <br /> NUSEONL <br /> DERM <br /> Print Name <br /> SITE MAP IN UN17 IV FILE, ADDRESS: I 3U 9 �� s I a 1 —Ar <br /> WORK PLAN DATED: Date Issued C <br /> �) a Final Inspection By <br /> E l; ) Date <br /> Application Accepted BYDate <br /> Grout Inspection BY <br /> Destruction Inspection BY <br /> COMMENTS I CONDITIONS: PERMIT I SERVICE REQUI <br /> AID# RECD BY DATE G <br /> ACCOUNTING ONLY: CHECK# J <br /> PE CODES FEE INFO AMOUNT REMITTED r <br /> C C-57 Lettl�of A luthorization to sign permit_Encroachment d <br /> C-57_ WC— WAIVER_ <br />