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(C( <br /> �! !f <br /> San Joaquin County y <br /> Environmental Health Department <br /> 304 East Weber Avenue, 3rd Floor,Stockton,CA 95202 SITE <br /> �` (209)468-3449 Fax:(209)468-3433 Web:www.sigov,org/ebd MITIGATION <br /> Well Permit Application UNIT IV 1 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED VJ'A ^ON <br /> Application fs hereby made to San Joaquin County for a permit to construct and/o Inslall the warts described. This application Is made In compliance with San <br /> Joaquin County Deve/nloopmmeennt Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, I <br /> WELL LocationVlCrossSlreet f •�� Assessors <br /> — oc�r1{ ity ro ZIP :!: 7 Parte 23 340,0 py E <br /> PORmerERTYI. ni3 X. ` , dress228IP2/�(•lubjI lntN �- NM} Zp953Y�3 <br /> J city V�tln t i Phone# g0.: s86-93$$ ! <br /> CST Contractor re!e iam (in Address23 S�Ji Um D( c v �y <br /> CoriaullaM/Sub Crdr II fOp 1 pR5. A5LJc&636387phone#2Tq qb •�7f2 <br /> -td. _ A dmss2395i^.I�nrnLlpro�vr clly. t uc*ce (p5L519( Phowzp9 g33,0758 <br /> g1iC nL. <br /> GIS Coordinates:X y Z I 1 <br /> Tovmship Range Section <br /> NRI WORN TO BE <br /> - ERF uen• - - <br /> g NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-)+ `abESTRUCTION (shoos below9 <br /> p SOIL BORING# OVER-BORE, DIAMETER S <br /> O'Olher# Man.— .f1�J?•2 'HN,iM=1�Y~S,�Jn1.6r Mw7 MW-S Mvl cd ed <br /> 'I, / r Sr OUT SPECFCATONS�Qu�dp(i n.QS s <br /> COMMENTS:-'�'LGU1 zr 4 �? 9R y o/GeaYl�...� J <br /> ZYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> --XUONITORING g HOLLOW STEM DIA.OF BOREHOLE_ g MULTIPLE CASINGS g A7ULT4LEVEL WELL CASING DIA: ' <br /> g EXTRACTION g AIR HAMMER/DRIVEN CASING THICKNESS -- C <br /> TYPE OF CASING: 11 STEEL 0 PVC a OTHER: <br /> g VAPOR 1 <br /> D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS g HOSE <br /> a AIR SPARGE/OZONE 0 PUS"POINT(GP or CPT)GROUT SEAL PUMPED: Yes <br /> 11 SOIL BORING 0 No (NOTE:MWMUM FREE-FALL DEPTH IS 36') <br /> 13 HAND AUGER GROUT SPECIFICATIONS <br /> N OTHER: n OTHER v- APPROX.BORING DEPTH S BOLTED TRAFFBOX or Q STOVE PIPE E <br /> CONDUCTOR CASING PROPOSED - (H YES,IIsi specifications pecifications In comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> O <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordlna ce .Rules and(Kiegul tons,and all applicable Cal(forr�t�State Laws. 1 " I r I <br /> Signet!x "tv.,t TIIWCompany I�reS�d fr,�-PJ riq{Tt�yTyifonm Cn�nQSet vi cts,l <br /> Pdnl Name J o Nn Lin— .h I - (3 <br /> i Date_ <br /> DEPARTMENT USE ONLY.,, NONd•coP <br /> SITE MAP IN UNIT IV FILE,ADDRESS: -53P5 E_ /h .SY <br /> 7;ili,' <br /> WORK PLAN DATED: jyF GSL <br /> Application Accepted By Dale issuetl —1 a Q <br /> Grout Inspection By Dale Final Inspection By Dale <br /> Desbucu n Inepenilon By Date —Z�l .'Z <br /> COMMENTS)CONDITIONS: 'f <br /> ACCOUNTING ONLY: AIDS 3 1 <br /> FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'DBY DATE PEFE�M7 <br /> QUEST• INVOICE <br /> 02 W <br /> S7 <br /> -57 WC -WAIVER_: C-57 Letter of Authorization to sign permit-iL Encroachment doc <br /> ,i2zJlM-dz-ool <br /> Ole <br />