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f COPY <br /> SAN JOAQUIN COUNTY <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street,Stockton,CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:yvwyr siaoy.orolehd UNIT IV <br /> WELL PERMIT APPLICATION pN WD <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ' Application is hereby made to San Joaquin County for a peril to cons(mr-land/or install the Ymrk dasaibed, This application is made in compliance with San <br /> Joaquin COLI Ifly DevelopmentTille chapp�lter/411IS.3 and TheStandardsof San Joaquin Counly.E�/nrvvvTon"'m'enlal Health DeepaarmeeriL <br /> Well Logationpv/�_ ��g Cross Street _66 �L ��7� / ily _!.__u�x_ZN J Lav ParCEI#AsSessors�3a <br /> Property 577&t? jU City/QTY} Zi5 Phone# 0yyy <br /> ' Owner�p ��,�a�/lddress � Cil t��J��G1YJ ��_ <br /> C-57 Contractor '$Z (. ���t1�Addless �tC�N .�a.41' - �}�., �" L L) <br /> r y Uc# Phone��.JJ U�_IcS a��V�7) <br /> ConsullenUSub Cntr�-7Ec� Address Py j3" �� City Q „tiy(l -L' r_ Uc# Phone(✓/(//7 ,�y <br /> t GIS Coordinates:X 1 3-F.�I 5 ,Y; -(ZI . Z 'Township -� Range_.L- Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELLJBORING!CPT,GEOPROSE.HYDROPUNCH.HAND-.AUGER.OTHER-) DESTRUCTION(CHOOSE TYPE�L <br /> ❑SOIL BORING# OVER-BORE DIAMETER lv <br /> ' ❑WELL# � --`�— GROUTSEGROUT <br /> ❑'OTHER(_ ,ff GROUT SPECIFIC(A')TIONS <br /> COMMENTS:- '1'7J(r 4llaA�.vrL}I?� MOyI J tDf WG��4 ,(/6! W" �j�-a- W—3.YFO <br /> U n�` <br /> ' RETS' _OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _ v <br /> MCNITOPING /9MOLlO'.V STEM DIA.OF BOREYOLE O•P9 p'{� <br /> []MULTIPLE CASINGS LI MULTI LEVEL WELL CAS1I4G DIA J (� <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS_ TYPE OF CASING 0 STEEL P(PVO ❑ OTHER <br /> ' ❑VAPOR ❑MUD ROTARY DEPTH FGROUT SEAL / ..i TREIME TVPETO BE USEOXAUGERSO NOSE <br /> ❑AIR SPARGEOZONE ❑PUSH POINT(GPORCPT)_GROUT SEAL PUMPED 0 Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 899 <br /> El SOL BORING ❑HARD AUGER-.- GROUT SPEOFICATIONS <br /> ' <br /> [2 OTHER: (3 OTHER. APPRO%.BORING DEPTH 3e bn�.__ []BOLTED TRAFFIC BOY OR ❑STOVE PIPE X/ <br /> CONDUCTORCASINGPADPOSEC AYES.I:sscpai�rv-cnsMtcmrnrp> ) <br /> COMMENTS:_ 5 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the workwlll be done 1 accordance with SanJoJoaqu/Irt County Ordinances,Rules and <br /> Regulations,and lapplicabla Call/o aLaws. r <br /> Title/Company <br /> r <br /> ' Print Name P�f �—Date��� q <br /> DEPARTMENTT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ( - Ic.Ct'�'� FOt; Z���Q <br /> WORK PLAN DATED: -_-_ _ 09 ([/ <br /> APPLICATION ACCEPTED BY DATEI &W–e- --DA—AREA O� / <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE �dDY <br /> DESTRUCTION INSPECTION BY DATE IO Uf <br /> COMMENTS/CONDITIONS: <br /> i •` <br /> ACCOUNTING ONLY:­- AID# FAC If <br /> PE CODES FEE INFO AMTREMITTEO CHECK# RECVDBY DATE PERMIT/SERVICE10 INVOICE <br /> 0 . 23 R#05 <br /> C-57 it WC V -WAIVER . C57 LETTER OF AUTHORIZATION TO SIGN PERMIT __ENCROACHMENTOOC ALPI <br /> EHB'a- t 115,oT 1YvI ftM I APP <br />