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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE ;. 600 East Main Street, Stockton, CA 95202-3029 MITIGATION Telephone:(209)468-3454 Fax,(209)468-3433 Web:www.sigOV.o[glehd UNIT IV WELL PERMIT APPLICATION _ -L4L)N-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct andtor install the work described. This application Is made in compliance with San 444 Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. rs WWI Locsdorl 1 d►anr►�e.� �{ cross street �[ +o�c --_ city� ap DZ iPr� 41000 t P owner t� Witr1[�V y�.10� 104f'd{Address � � S'�•. .S�_�I�2C City k/.�a�giP �`i _g� 8'Phone# lot,C-57CorM=kr 1R1�11 OMC .C.%37- OC. Of C6ZWJ * Zlpt&.tic# v1 d PhonekW. ConsultarrUSub Cr& AddresQ5D El 4MI)l'5k 17,15'17,15'City f;ISOW-1- Lic# Phonew.h,ftS. ; tlMg GIs Coordinates:X Y Township Range Section WORK TO 80 PERFORMED, ©NEW WELUBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(CHOOSE TYPE BELOW) [I SOIL BORING# [IOVER43ORE DIAMETER ❑WELL# P.PRESSURE GROUT ❑"OTHER GROUT SPECIFICATIONS � . l y [3 EXPLOSIVES DETONATING CARD, COMMENTS:_Myv`13 M Y MW-M Q Dt'1IS 91f C gkfo i1 4- aWg-4 r t11 Abd .5 1;t,a TYPE-OF-226 INSTALLATION TYPE 9!2N TRU0j2h =IF19MONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:____„_ ❑EXTRACTION ❑ArR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER ❑VAPOR 13 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE • ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH 19 301) ❑SOIL BORING ❑HAM AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING PROPOSED (If YES,list specifkatians m commeM secWn) NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 1 F 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 1 hereby e w ft that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable CaIN4Mb Laws __ __ Signed Titl Q elCompany Erty &%A Spee o l iSi _-- Print Name 6.�-� W4,11 Date • Q I( + DEPARTMENT USE QNLY SITE MAP IN UNIT IV FILE,ADDRESS: D S WORK PLAN DATED: 2 I APPLICATION ACCEPTED BY LL��twnnPl � DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE Ft COMMENTSICONDITIONS: F ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMf1"TED CHECK# RECVM BY DATE PERMITISERVICE# INVOICE z�r r a SR# 6 (—'57-WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN RMIT ✓ ENCROACHMENT DOC END 28-01 10/28109 WELL PERMIT APP L { 'tea