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FILE 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:www.siaov.or0/ehd UNIT IV <br /> 1 <br /> WELL PERMIT APPLICATION orf A- fr�t/' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �/ „ y 7— <br /> Application <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 Title,chapter 111115.3 and the Standards of San Joaquin Copbty Fsvironmental Health Department <br /> JkI�O�.v+ /I • S / Assessors <br /> Well Locaton 3;�l I✓es�'Be 4 Goss Sweet Cu n3����{yon/T� City_5c,kG .` Zip 9$Zl9 Parcels !00/7003 <br /> Property <br /> Owner ,'T.axw/� k;A' Address 3�'y3 10r..:..s,..lti�.✓� City Zlp Phone# <br /> —� <br /> C-67 Contractor �v1, � Address RS'O//ni„r,Pe�„f City yUCtl `y�Phone 91531$-Sd'0o <br /> ConsuitantiSub Cntr[30..ppec .. Add ress 4�9 ,1'..cIj.ONverSr+k ry ,a CA 4i�t?iR Nh Phone 707-Y33-236f <br /> GIS Coordinates:X . QOS ,Y-121.353 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) aDESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORINGS I]OVER-BORE DIAMETER <br /> Ll WELL* 1 h PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS o- Cc_ we-. , •` <br /> COMMENTS: 14115 <br /> 6�1�L <br /> v r 1 <br /> TYPE OFWELL INSTALLATION TYPE ' CONSTRUCTION SPECIFICATIONS <br /> ICLMONITORING ❑HOLLOW STEM DIA.OF BOREHOLE �Ao MULTIPLE CASINGS MULTI-LEVEL WE1.LCASINGDIA:_2L_".# <br /> ❑EXTRACTION ❑AIR RAMMER/DRRIEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC 0 OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL !-f,4 TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)__,_GROUT SEAL PUMPED:N Yes 0/No (NOTE:MAXIMUM FREE-FAL ') <br /> L DEPTH IS 30 � <br /> ❑SOIL BORING LI HAND AUGER GROUTSPECIFICATIONS Pz'i&_j L-e..�A <br /> 0 OTHER: ❑OTHER APPROX.BORING DEPTH EA [I BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONG1Cr012 CASINO PRORISEn (I(YEe,AA rpacEa6evhoamrY wuwq <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby cerrNy that 1 have prepared this appikatlon and that tho work will be done I accordarnoe with San Joaquin Comity Ordinances,Ruks and <br /> RSBuiatkns,an"appli <br /> ca <br /> ble California Laws. - <br /> Signed � .-,L1 Tdle/ComPany t/- <br /> Print Name _ Date <br /> 2 <br /> DEPARTMENT USE ONLY 2-?-S7 <br /> ' SITE MAP IN UNIT IV FILE,ADDRESS: .3D I e ,BEI(/ 1 <br /> WORK PLAN DATED: LY <br /> . APPLICATION ACCEPTED BY DATE ISSUED O.O 9 AREA 0600V <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID If FAC0 <br /> - PE CODES FEE INFO AMT REMITTED CHECK t RECv'D BY DATE PERMIT/SERVICE nF INVOICE - <br /> 2 w 6-12-- f z#05 . 3. <br /> 037 If WC tZ -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENC ENT DOC <br /> ERDSa0/ IIF"WA �'M p fFla0.fit.t.6. <br /> ra.w- <br /> r1t COPT- <br />