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FILE COPY <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton CA 9520 (hd ITIGATION <br /> (209) 465-3449 Fax: (209) 46g-3433 Web: wwwsjgov.org/ . I UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED W 5 <br /> Appllcallon is hereby rnede to San Joaquin County for a permit to construct ondror install the worn desrvibed, This application Is made In compliance with San <br /> Joaquin Cour, De eiopmont Tme, Chapter 81115.8 and the Standards of San Joaquin County Environmental Heafth Department. <br /> WELL Locadan I°� YJ� If,�'., ) DO�ula 5�, crew streaal. Nvn��, A clly 5fa zip a a Pa'� st <br /> PROPERTY 41 ! C ( Uh1 ,gddreao " '^'`..C_ 5. <br /> Ovmer. fJl Jto_ �1Cvl fL1i, -,. , ,,,� city, zip <br /> C-57Cartraaor irlli A� tl"tless� flpwF cly/ ✓ n( zp Lck �gSIGS Pho e# 253 -5b�o <br /> Consultant [Sub Cntr ia.�Ji �adt(o_,�, w,�+^ry dd esf� �awWmina pP, ' 5'Dp,y��� 1566 Phone# 5?o-f:�&r?0412 <br /> G19 Coordinates: X ��. DZ I . Y — I Z l .3 IS , ra v' ship Rano . section <br /> w R o• <br /> EW WELL / 90RING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose typo balov� <br /> 13 SOIL 80RING l 19121 _ D OVER-BORE. DIAMETER <br /> 0 WELLi 0 PRESSURE GROUT <br /> 0 `Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATIONTYPE CONSTRUOTION SPEciriCATION3 <br /> '+MONITORING HOLLOW STEM DIA OF BOREHOLE nL0 MULTIPLE CASINGS d MULTI-LEVEL WELL CASING DIA,-Z 1 <br /> D EXTRACTION 0 AAR HAMMER/DRIVEN CASING THICKNESS�.4D Y TYPE OF CASING: Q STEEL VC p OTHER: <br /> VAPOR g MUD ROTARY DEPTH OF GROUTSEALas� 55 TREMIE TYPE TO BE USED: 0 AUGERS 13 HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: )VYes9 0 No ( OTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0SOIL BORING 0HAND AUGER GROUT SPECIFICATIONS lu74 <br /> 0 OTHERS OTHER APPROX. BORING DE IPT �)WI30LTED TRAFFIC BOX or d STOVE PIPE <br /> CONDUCYOR gnS1NG <br /> COMMENTS: 2 PROPOSED (i( y", list spedflratlons In Comment section) <br /> DI_ r <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin <br /> County O Inanc Rules and Regulations, and all applicable California State Laws, <br /> Signed Tine/Company '^ LS 7Yt+Y� �ny/,tyr y__ X4• 1 <br /> Print Name 56 "Ad Oate — 1 �Q <br /> DEPARTMENT USEI)KILY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: Z <br /> Application Accepted ate Issuaa Area d1 <br /> GrwA InspectionBy Date 27 .91 / 6 Final Inspection Sy <br /> Destrvcton Ins cdon By ata <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INTO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT sERVIC@ REQUEST INVOICE <br /> 8� SR#R / 9Z <br /> G 57WC -WAIVED_ C-57 Letter of Authorization to sio permit.— Encroachment doc_ <br /> EHD 29v42.Op1 <br /> W2104 &95 in <br /> 7// � l - <br /> E9 /Za 3DVd dI -1VO ON sniv?J1S 59999L996S 96 : L9 L09Z / sT /6e <br />