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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> X11 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 lNeb:www.siGDv.Druiel'd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San <br /> Joaquin County Deve opment Title,chapter 1115.3 and the Standards o n Joaquin County Environmental Health Department. <br /> 11 S� '/'t ,,`���I�� Rb• 7h,,ww An Ka rp / Assessor's <br /> Well Location J�� %7T(ZIC//v� Cross Street A/6 f/r eorr/ iC/ City nodi Zip Parcel#O55-l�D-J(p <br /> Property <br /> Owner 67)" of LOP/ Address � City Zip Phone# <br /> C-57 Contractor �nr�n—DJrl� Address 95� ,COf}D City fQ�!'ne� Zip9�553 LID# // Z Phon <br /> Consultan SubCntr_��i. Address 3.yQtLr'�XQSfI rCtJ- City ' /�Lic# NA Phonq� �O7l-.�5� <br /> GIS Coordinates:X ?0.O88�i .Y l2D. : Fl .Township ry Range 5 E Section <br /> W K TO B PERFOR <br /> NEW UBO RIN ' P E PROBE,HVDROPUNCH.HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING#� ❑OVER-BORE DIAMETER <br /> ❑WELL,Y ❑PRESSURE GROUT <br /> ❑-OTHER lz'+'S I GROUT SPECIFICATIONS <br /> COMMENTS: 526-FE.ETa A-DP4E55 - 5 Al77homlDyJ . J' CST— <br /> , <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [IMONITORING ❑HOLLOWSTEM DIA.OF BOREHOLE _kr� El MULTIPLE CASINGS 0 AtUL T bLEVEL WELL CASING DIA', <br /> 0 EXTRACTION ❑AIR HAMMER/ORIVEN CASING THICKNESS TYPE OF CASING:0 STEEL 0 PVC 0 OTHER <br /> 0 VAPOR 0L7 ROTARY DEPTH OF GROUT SEAL - TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> 13 SPARGE/OZONE PUSH POINT(GP RCPT) GROUT SEAL PUMPED:0 Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS AIA,4r <br /> r , 9 LA r 7 <br /> rvrX! / 4 //O//S O Lr-Lt � <br /> 0 OTHER. ❑OTHER: APPROX.BORING DEPTH 5D ❑BOLTED L FDIC BOX bR 0 STOVE PE <br /> CONDUCTOR CASINO PROPOSED fd YES.+tai soocnw�icnzm mmmem mccon} <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations I appli a�Ca If rniaaf -7;;+ /- <br /> Signed 7- ��lf7.G2LLL _TittelCompany 52 E.N& eiEg Ih i4-2Al-Z'w G`1lrt U�l2 t N6.)Aje <br /> Pnnl Name J -'� MA`TTt' S� IS- _ Cate z7 MAV oag -------- <br /> i <br /> DEPARTMENT Y <br /> `USE ONLY <br /> S172 MAP IN UNIT IV FILE.ADDRESS. X11-51 W 1 rioy3gw lam. _ - <br /> -NGRK FLAN DATED. <br /> APPLICATION ACCEPTED B- Q-'--ISSUED -� 5--P,2cit Lt <br /> GROUT INSPECTION BY _ FINAL INSPECTION B' /4F4VK lL DATE 6��L <br /> DESTRUCTION INSPECTION BY __. DATE <br /> COMMENTSICONDITIONS: tb OS ' ���1_06M48'. "r-k- CAfYC_ LO(e,..D N? = C;r,S rwfh.,kIL_ <br /> ;'CCOUNTING ONLY: AID;; FAC# <br /> ' PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVI <br /> CE# INVOICE- . <br /> 1.,'Gf\nl 8al.�J 4 ge.oJ ! 3(,843- s� o� �R#sR3gr� �.— <br /> C-57._ t/ ',VC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC ,_ __ <br /> ..__.'EOMIr AP' <br />