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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE <br /> *.�) <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www siDov oro/ehd MITIGATION <br /> UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to Construct and/or install the work described. This application is made In compliance with San <br /> Joaquin County Development TRIe,chapter 9-1115.3 and the Standards(,of SanJoaquinCounty Environmental Health Department. <br /> Well Location -VS4 Am bee Amp Cross Street MA �Y^[IL.I/ Yr C 'r- Assessors /� <br /> Property <br /> dY `I Zip 9 3 Parcel# /{ .Of tv <br /> Owner ['.}At F�T.rgr,,,t_ Address _5w T—,rr&,� Cm, Zip95376 Phone tt <br /> 0-57 Contractor Address GIS$0V_�4:Zj 93?) Cit _(5'30)616- ' <br /> n'' f,` --- - F&VU yMOYwl. Zip�SlYlr7j Phone <br /> Consukanvsub Corr-. �tZM Fh(4 Addressill City r„�,rr}mc,n{o Llc#, _phone. 46 Zsb -O QS <br /> ^� Oc L9_. ----- - <br /> GIS coordinates:XJ ib 4br S'1 I M ,Y !Z k Z A I �j4.At ,Township L&L .%(y,n^j C.,.;k Ca Reng@' Section <br /> WORK TO BE PERFORMED: <br /> N NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER' ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ®SOIL BORING# M4c11+ �� - tr{ •-+ r, �*i(� 11 OVER-BORE DIAMETER <br /> ®'WELL* ) I PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> 8`` 1 <br /> [I EXPLOSIVES DETONATING CARD <br /> COMMENTS: II bwY w �A e 1 'e:ll a 2 w•.�+ jl-x O-xL Mb •-�GY-` N.{t C <br /> TYPEOFWELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIOtL <br /> MONITORING 64 HOLLOW STEM DIA.OF BOREHOLE x;, ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:�r <br /> ❑EXTRACTION ❑AIR I-IAMMCRIDRIVBN GASSING TI IICKNESG Mt}HO TYPE Or CAGINGo❑STEEL 4 PVC ❑ OTHER <br /> ❑VAPOR m MUD ROTARY DEPTH OF GROUT SEAL In b ZQ_TREMIE TYPE TO BE USED pct AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE O PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:l ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ®SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ',r,Wr <br /> ❑OTItCR: ❑OTHER: APPROX BORING DEPTH ^ t A' 60' OFSOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASNG PROPOSED (r YES•list r.MG in rammanl se4ion <br /> COMMENTS: � ) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that i eve Prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,s. Witble California Laws. <br /> Signed Tibe/Company C1{7_M <br /> Print Name Gk r:s+api,�Cr <br /> 1 <br /> DEPARTMENT USE ONLY <br /> 3RG MAP IN UNIT IV FILE,ADDRESS: AU-(/ . ,��AI` ear P/Lo r d/_ <br /> WORK PLAN DATED: DU !,/ Zr)� U p 1� 7 <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA 94'7 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: =CHECK <br /> . �a G 20 (O <br /> ACCOUNTING ONLY: AID# F!AC 07 <br /> PE CODES FEE INFO AMT RRECV'D BY DATE PERMIT1sERVICim 4`1-9'0I [f" l/ !v s9 SRAOe <br /> C-57 WC -WAVER C57 LETTER OF AUTHORIZATION TO SIGN P MIT ENCROACHMENT DOC <br /> EHD 2"1 IMSIOB <br /> WELL PERMIT APP <br /> PK Tyr- 3YS- c_ <br />