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J • w FILE COPY <br /> SAN JOAQUIN COUNTY <br /> a ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> j 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:WWW.SigoV.orGlehd UNIT IV <br /> WELL PERMIT APPLICATION �^�/,y' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDv' ��/��/ y <br /> , ' - b r ' <br /> Application Is hereby made to San Joaquin County for a permit to construct andlorinstall the work described. This application Is made In compliance with San <br /> Joaquin County Development TI(le,chapter 9-1115,3 and the Standards of San Joaquin County Env)'uonmentaal Health Department. <br /> Well Locadonjg j/ lJia{'b°enJ ti+•^H`Clsessors <br /> ms sStreet(nnc��� a^A-c>^'t r CI(y .SI'y c lGr�. Zip 1521 4 Parcel# [oo l RO l!> <br /> Pro City5 -,41n. Zip1.5Zf— Phones A/R <br /> 6a-y Y•3D <br /> C•li7 Cuntrecfor Atldross 9,�0 EF^vim Qv,�r "CSity Maw Lk# Y,VS/GSPhona 425-313-5&tXJ <br /> Cone ultan88ub CntrG,nppw A-1Za�rr3 Aaddrrerss r',it7 Xveis Dom.Bey-5•••k'City $�r�g �c#��NR Phone'70-7-933-2369 <br /> OISCoordlnates:X 30. 005 ,Y— '2-1. 353 ,Township Range Sedlon <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELUSORING(CPT,GEOPROBE.HY ROPUNCH,HAND-A R.OTHER'yy�� DESTRUCTION(CHOOSE TYPF)PELOM <br /> 0 SOIL BORING# �,A i-0 12 VER-BORE DIAMETER — "& / U <br /> 0WELL# p / PRESSURE GROUT O <br /> ❑-OTHER Z-p y GROUT SPECIFICATIONS or •..f' <br /> COMMENTS:W I L.." 'Aa 3 — i0- <br /> l a �•, f4 �: ,. rr -4a� Ld <br /> tM C <br /> d�WELt INS LATIOWTYPE CONSTRUCTION SPECIFICATIONS r� <br /> MONITORING 0 HOLLOW STEM DIA OF BOREHOLE _& Cj MULTIPLE CASINGS 0 MVLT4LEVEL WELL CASING DIA:C� (�\` <br /> ❑EXTRACTION 0 AIR HAMMERMFUVEN CASING THICKNESS�I�i_TYPE OF CASING:0 STEEL n PVC 0 OTHER ` <br /> O VAPOR - 0 MUO ROTARY DEPTH OF GROUT SEAL &A.. TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> 0 AIR SPARGFIOZONE 0 PUSH POINT(OP OR CPT)_GROUT SEAL PUMPED:XYes 0 N/o/(NOTE:MA)(IMUM FJREE-FALL DEPTH IS DO') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS r 44� �/.�G—•T" <br /> 0 OTHER 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR O STOVE PIPE - <br /> CACH�UG7 11 PBCPoSED (fl YES,Ist h ) <br /> COMMENTS: Aw <br /> NOTE: OFFSIT .r INGS REQUIRE ACCESS AGREEMENT; ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby cerdly thal l have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Re6ulattons,and all applicable Card nla Laws. / - <br /> Signed // r T1twCempamy .Ge c,+of <br /> Print Name SCu f 4 _:S Date L —ZZ—U7 <br /> DEPARTMENT USE ONLY \/�,, �p [y 2?5'-7 �F <br /> .SITE MAP IN UNIT IV FILE,ADDRESS: 30�/ G� J /p WW l 5/ W 057 <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED ;r•9-()4 ARF11..Obe� <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK* V'D Y DATE PERMI ISERVICE# INVOICE <br /> Wh 124D2.3716-12 -69 SR# 6 <br /> C-57 M •WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT A ✓ ENCROACHMENT DOC <br /> EHD=1 IIAWIY�8) V/� WELL PBiNIr APP <br /> c �i c r+nov <br />