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c <br /> ?IU <br /> SAN JOAQUIN COUNTY ORIGINAL <br /> ENVIRONMENTAL HEALTH.DEPARTMENT SITE <br /> it <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Ted®phoner(203)468-3454 Fax:(269)468-3433 Welt:www,siaov.ordehd UNIT IV <br /> eW� <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED <br /> Apptiwibil'Is hereby made to San Joaquin County Pore permit to construct andlor Install the work described. This application.is made In canpllance with San <br /> JoagWn County of wopmantTim.chapter 9-1115.3 and thee Standards9f San Joaquin County Environmental Health Department. <br /> /41 T t`f�- Assessor's <br /> Web Location 5 u+S loss Street 10) C :ity S/d c I AR, zip 9,5� 7 Parcel#M 7-,9>l7-L'9 <br /> Property Xe 'lp 1 <br /> Owner 94 .ate. hN to "L-4 Address 77aoG/feat ' bi-. city.Sn:ceati.ea 4 Zip 5=L Phone#5/d-396-8800 <br /> C-ST Contractor Te7Za-./Iiy Yws'r(DN Address 7/:35D/louitr a.r.. PACE City�w-rCr+O[dY1rVa.ZirRs'ry241c# 76�''qZ8 Phor1e <br /> �t,,n�+��1 yyjj-"'b <br /> Cotrsuitantigula Cntr j4d_C bI S' Address All - / /10: . CIty&VyV1AfLlc# PhonaS76 L7'X•Y3"ry3 <br /> GIB Gwrdinates:X 3g•Dl0 Y --12-1- 12-2 T i>;ho Range Section <br /> WORK[ EN W O80 EIgaRiNGN((CP l EOPROBE,HYOROPUNCH,HAND.AlN3ER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> �S'C-f- �� Q OVER-BORE DIAMETER <br /> ❑'WELL# _ ❑PRESSURE GROUT <br /> ❑`OTHER OROUrSPECtFlCAT[ONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> V\ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTIONaPECIFICATIONS <br /> 0 MONITORING' ❑HOLLOW STEM DIAOF BOREHOLE I ❑MULTIPLE CASINGS E MULTI-LEVEL WELL CASINGDIA:,_, <br /> _ O�EtTRAtMON 0-AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:O STEEL 0PVC ❑ OTHER <br /> Bl'YAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL _ _TREMIE TYPE TO BE USED O AUGERS CI HOSE <br /> D AIRSPARGOOZONE U*OSH POIHr(GP OR CPT)_GROUT SEAL PUMPED:D Yes O No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL90RING 0HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER:. D UTHER; APPROX.BORING DEPTH "r 0 BOLTED TRAFFIC BOX OR OSTOVE PIPE <br /> �' rANO FTk1R IBO PROPOSED��, (If TEe JMspecYace <br /> COMMENTS: ix�'lA.sr- A W / OG,ry,. Mu n/ [.....v: der L�.�_ rnI t,, <br /> NOTES 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 1 accordancewith San Joaquin County Ordinances,Rules and t, <br /> Ile <br /> Regulations,anZbike C-a>l+if,o-�rnia Laws. Ttle/Oompany d',4G7-Z/ K(A F! <br /> /Siowd ! <br /> PrkrtNaide Date <br /> DEPA#>T{Y4E�1NT USE, ONLY Z`16O <br /> SITE MAP IN UNIT IV FILE,ADDRESS: r r. �.c+;+�-/PD'�O <br /> WORK PIAN DATED:. !/ _ _ _ A <br /> APPLICATION ACCEPTED BY - - AREA CL/VNL�!/ <br /> .a <br /> GR <br /> OUT"PECTION BY FBJAL INSPECT 161 RATE <br /> DESTRUCTION INSPECTION BY DATE <br /> -COMMENTS/CONDrT)ONS_ <br /> ACCflUNTFNG ONLY: #. FAG# <br /> iE 60DE$ FEE)yF0 AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICS S INVOKE <br /> SB 3D 5-3.10 tt) <br /> C-B7 so, WC W, -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V Ems, TDOC <br /> EHU:2"11028)08 <br />