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• • FILE COPY <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 SITE <br /> Telephone:(209)46&3449 Fax:(209)468-3433 Web.vwvw.BiooY ordehd MITIGATION <br /> ~�O� UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLEPERMITExPIREc i AR FR(til Hort) SUFn <br /> APONcabon is hereby made to San Joaquin County for a peffM to mistruct and/or in wont OV %, <br /> Joaquin County Development Title,chapter 91715.3 and Staldads of described- TMs appicallion is made in compiance with San <br /> Joaquin County Environmental HeaNA Depa a ent. <br /> W40 Loea �{�,�kl,n,} �� Cross Street ^� ���� ` <br /> off« �;mP/Fha�TI�P�m��f+nlAddress Ilu�7 F. .v ,►l;w l Glry !/��7 / Pa ' -lfO-W <br /> ,,c�--�— City Tate _ ZP 9f�9 f Pha,e M <br /> C-57 Contractor . f! ' Address ,Q ,T <br /> �/yy /ycity c r oe X 30 yh1-3600 <br /> Cort&uKsnVSup Cnh 171yZ��. - Address llNV lDd�rtA'I� i°tYTi:ty Li�M Phone -!, <br /> jj <br /> GIS Caoralnates:% 37.7: I �L'--17-1.5 ZZ / R wl� t�Swoon <br /> ,ipWnsllq 6� ) C�- L 0 <br /> y�y{pRK TO BE PERFORMED: <br /> ANEW LLfBORING(CPT,�EOPROBE.HYDROPUNCH.HAND-AUGER.OTHER-) <br /> ` SOIL BORINGN " ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> WELL N ❑OVER-BORE DIAMETER <br /> ❑'OTHER ❑PRESSURE GROUT <br /> COMMENTS3e GROUT SPECIFlCATIONS <br /> : ./" <br /> TYPE OF WELL INSTALLATION ryp <br /> C,ONSTR u'Tw+.r SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DU.OF BOREHOLE —'/' <br /> 0MULTIPLECA-SWGS❑MULTI-LEVEL WELLCASINGOIA:_ <br /> ❑EXTRACTION ❑AIR HAMMERiDRIVEN CASING THICKNESS <br /> TYPE OF CASING ❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL —— <br /> TREMIE TYPE i0 BE USED❑AUGERS❑HOSE l <br /> ❑Z//AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPn_GROUT SEAL PUMPED:O Yes <br /> pp \ <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS /'kTNu (NOTE:YAx1YUY FREE-FALL DEPTH IS 3B) <br /> ry (` <br /> `❑�OTHER: OTHER:I I���,��i1p t APPRO%.BORING DEPTH i -7 iPPL <br /> COMMENTS CONDUCTOR CASINGPROPOSED O BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> pVas ev�+tirranns�� ,e,esxtiml �(' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKBVG HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I RagldaKonshereby nS al Wet I haw PreparCaledKids kPWN-Mm ar d that the worlr-W be dors 1 accordanceKKan wSJ <br /> ,an aK apyll 1 omi Yaws. i oagWn Cowry OTAnanps,RuNs and <br /> Signed l <br /> ralNCompa" <br /> Print Name - <br /> para C <br /> p DE ARTM <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �d <br /> APPLICATION ACCEPTED BY D <br /> D <br /> GROUT INSPECTION BY FINAL INSPECTION AREA e6 <br /> -- DATE 9 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSCONDITRM: <br /> ACCOUNTING ONLY: AID M FAC/ <br /> PE CODES FEE INFO AMT REMITTED C ECK/ RECVJ)BY DATE <br /> PERIIN7/SERVICE• INVOICE <br /> 0 <br /> 040116 _Zj S <br /> Ew as-0I <br /> C-57 WC -WAIVER C57 LETTER OF UTHORIZATION TO SIGN PERMIT <br /> E ACDOC <br /> tffnlsn>lu�el <br /> I(f� WELL Aw <br />