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• �p,,IMrf $ ybSoT <br /> q p-1\ <br /> �,/o.-�.:,,,�r:�i $AN .IOAQUIN COUNTY <br /> 11 ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> e �} K <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.siqov,ojrq/ehd UNIT IV <br /> �<ikggN� <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to Sen Joaquin County for a permit to construct andlor install the work described. This application is made In compliance with Sen <br /> Joaquin County Development Title.chapter 4-1115.3 and the Standards or San Joagepn County Environmental Health Department <br /> Well Location r7� +el ` <br /> it C_ �W.l2f. (Cross Street /' ��f��� ���1 (G k( Assessors <br /> ��I �n -`� __tr�7ir,� riuc /'�y / IlY '.'rG'� Zip ( ^, lxarrsl# S/( <br /> Property .V" p 'Y" •� �'V YJ 7�I� 1A Sd , SQL ,.5�'}/ <br /> Owner_ ��T,,, �' _ Address �_.. � City Zip 5� Phone yl.OkJ- <br /> C-57 Contractor KRAi?ArO tA55cc. Address .Z I S A9KoTA/-IUB._ Cil C,/_Oy15 _ z SST- <br /> - Y Zip tic# Bg Phone 3`I$v�2D0 <br /> ConsuitantiSub Cnir Address I--5_5' e*0- C,14ORr2� Cil TUI.Aae <br /> �1-7 (� �1 9 �1 1 r uD#8}o�Ys pnone�6gH-}zov <br /> GIS Coordinates:% d I+ I �77`� ,Y ^�d �1'Op��,Townshi A� <br /> P N Range Section `/ <br /> W K TO B RFORMED: <br /> MEW W UBORING ICPT EOPR ,HYD OFU:NCH. D-AUGER,OTHER y ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> OIL BORING# '� - N4' -_ ❑OVERBORE DIAMETER <br /> ❑WELL# El PRESSURE GROUT <br /> [I'OTHER GROUT SPECIFICATIONS <br /> ___ <br /> ❑CXPLOSIIVV.EE�TONNATINCLCARD <br /> COMMENTS: IAT*aj IdfA")Yt� <br /> TYPE OF WELL INSTALLATION TYPE CON TRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE -F.r,l ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:� <br /> ❑EXTRACTION ❑AIR HAMMeRfDRFVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC [3 OTHER 1 <br /> ❑VAPOR ❑OAU OTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED p AUGERS❑HOSE <br /> ❑AIR�SPARGE1020NE USH POINT(GP OR CPT), GROUT SEAL PUMPED.p Yes No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> (�$/OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX-BORING DEPTHS <br /> CONDUCTORCASMGFiocpaaD BOLTED TRAFFIC BOX OR (]STOVEPIPE <br /> COMMENTS: __.__ WYts.Int fpeulirnwnan wnm�re aaewn) <br /> NOTE: OFFSITE BORINGS RJEQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> WO ING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that�Ihav,p r this app tion and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and allppii life nS. <br /> Signed -__ TitlelCompany—GAJ <br /> Print Name Dale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY �Ud+1+y��'eaa 1. DATE ISSUED AREA <br /> GROUT INSPECTION BY 1-2,%I10 FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID## FAC# _ <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D 8Y jD%ATE"PERMlTjSERVjCE# INVOICE <br /> agdt sqoo vtsA5 TIS <br /> C-57WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1012MS WELL PERMIT APP <br />