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' * Street,23' s/ I Joaquin County FILE COPY <br /> Environmental Health Department SITE <br /> 600 E. MainStockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> Well Permit Application' NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `r O - Ws-3 ' <br /> Application is hereby made to San Joaquin County for a permit to construct and/or krstail the work described. This application is made in compliance with San <br /> Joaqun County Dewlopmert Title,"ChapM 9-1115.33 and the StarMards of San/Joaquin County Envirormenral Heats Deparbneru. <br /> WELL Lowson 1958 1 MU�rL114 ,l V[.Dross Streww <br /> Assessors <br /> Z' <br /> l�OKy M�.+a��a•zp Perosis <br /> ' PROPERTY n�L l4 0 unSt Soma CI4M 5f- ' <br /> Owner D rA.1-M FOAA+S rnr— Address Sol;ft 990 City Sco4,7156. zip 9 S//,jPw"s 16, <br /> uSpi,A;v.rf 5�p„ct 1707 L,'Mf jQrc1t&�f sr sib <br /> C-67 Contractor c uc 1 Address 3ui}Y. A CYy.Strs+fO SC TipLid44SYu3prfOB Zq 7q-OGG/ <br /> ' L7k F,A;�aw.f ac6 1701 U Ff It CvoAoW 5 It •Sw3 , <br /> Comuttant/Sub Cntr COHshrrac Nn Adsdr-acsa Sm;ft •'f Cry OSC Lica�iLirl Phmea rFOBf4T9-0(a'i/ <br /> GIS Coordinates:X 37.n2- ,Y"IU' •!T 1 .Towmstup Ranger_Section , <br /> ' " K TO BE PERFORMED- <br /> WELL <br /> OR ED:WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-ANGER,OTHER) 0 DESTRUCTION (choose type below) \� <br /> 0 SOIL BORIN�i�a 0 OVERBORE. DIAMETER V <br /> MrMLL a Nl W - 1 , 0 PRESSURE GROUT I a, <br /> 0-Other' GGAR�"O��UT SPECIFICATIONS COMMENTS: 5 AC MA-7G A•� t(/'ac f IQM a.....� W-ta ACL.TZZt ScGlCM4A.'Fr•L <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )(MONITORING LOW STEM DIA OF SOREHOLE_� 0 MULTIPLE CASINGS MULTI-LEVEL YELL CASING DIA' 4 ( a 1 <br /> 0 EXTRACTION 0 AIR HAMMER/DRNEN CASING THICKNESS Sc6t 6 TYPE OF CASI I 0 STEEL PVC 0 OTHER: 1 <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Esh'traFe YOB TREMIE Tl(PE TO BE USED: 0 AUGERS XHOSE <br /> ' 0 AIR SPARGE 026NE 0 PUSH POINT(GP or C"dFI61J1`SEAL PI WO- 0 Yea 0 No (NOTE: OMUM FREE-FALL DEPTH IS 307 <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS PO•.t la" I Y Oi b <br /> 0 OTHER'._ n OTHER APPROX.BORING DEPTH 3d-40- OLTED TRAFFIC BOX or [[STOVE PIPE n <br /> '� C6N' DUCTOR CASfNG PR6POSE6 A)D (H VE9,list specification+In comment section) <br /> ' COMMENTS: AO�RS sy'Ci.Q. tD .4L F�1/tA,i�{( f0 tjrC gp td ;lY_L Crvt(.t j f-!M1A- <br /> NOTE: OFFSITE SORIN03 REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> ' 48 WO HOURS NOTICE REQUIRED FOR INSPECTIONS. I ' <br /> I hereby certify I have pre appllcation and that the work will be done in accordance with San Joaquin <br /> County Ordina ,R n u na,and all applicable CalHonda State Lawsi <br /> ' Sigrwaa rea/ctargany P/rnc. 1 C.r yi�<- A.�' dj ,.. ' <br /> Print Name_ ( Date to/to,06 <br /> DEPARTMENT USE O�NL,� � �• _,c-� <br /> ' SITE MAP IN UNIT IV FILE,ADDRESS: 1?5 7 S. ` �C.(�c( t UM?f <br /> WORK PLAN DATED: dr <br /> ' Application Acey Dasa Issued Area <br /> capted , <br /> Grout Inspection 8y Dale Final Inspection R ads <br /> Destrut"Insw ton By Data <br /> ' COMMENTS/CONDITIONS: ' <br /> ACCOUNTING ONLY: AIOF FACa <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS RECD BY DATE PERMIT I SERVICE REQUEST a INVOICE <br /> ' 2,1b I561 $ s 1 <br /> C-57--y" WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachmil I J <br /> ' X29-02-001web II-� C� ...r I_,�I11! <br /> F�� c rn oy juiq , 12,m <br /> ' ENl/IH0NP:1Ef4T HEALTH ' <br /> t <br />