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• ` ' • • <br /> 4o1!y <br /> SAN JOAQUIN COUNTY FILE COPY <br /> y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE <br /> Telephone:(209)468-3454 Fax:(249)468-3433 Web:Wwws' ov.or ehd MITIGATION <br /> —' UNIT IV <br /> (q) WELL PERMIT APPLICATION <br /> O REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE IS Icn <br /> ppP ban is hereby made to San Joaquin County for a permit to construct and/or install the work described. This <br /> Joaquin County <br /> //Development Title,,Lc{chhya�pter 9-1115.3 and thq,StarWards cj San Joaquin County Environmental Hear Department.Is made in compliance with San <br /> Wall Location�fyJJ {r`�c-'f'e �k eparirnenL <br /> Cross Street City laelz�or Assamrg <br /> Property Lr'.rem Prc .rf;.�r GT-O Zip F-S lA" Parcel#97-We-7,j <br /> Owner .{'tw. _ _ .Address ,37r/ L,'N[ol [' �,. <br /> "� Cily Sjroct�. Zip r1 .7 Phone#109-478-9a'iM <br /> 0,57 Contractor 4i' t/5 � Address /tom O r[;tr•pa,. <br /> Cityp?1ZIP 74Z <br /> Us <br /> 7Q a <br /> ConsuK 6ZI_Phone <br /> anVs.w Cntr 46Le^, b t C Address//rCU aDy_ll lam//F�d.1 city tr v,' l vK•tx3-pe7o <br /> GIS Coordinates:X $.nl O LIcR Phone 5/�y y� <br /> —�..___ .Y—IZI, 23 .Townshl <br /> WORK TO BE PERFORMED, p Range SeCWn <br /> GHIIEVV;��L;A�r�����BORING(CPT,G UPROSE,HYDROPUNCH,HAND AUGER OTHER-) <br /> MOLUtLL WELLBORING# ft �!c -2 CA-V Cr' L r 7 ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> 11 OVER-BORE DIAMETER <br /> Q'OTHER E]PRESSURE GROUT O <br /> GROUT SPECIFICATIONS <br /> QOMMENTS: <br /> ElEXPLOSIVES DETONATING CAR---p----- O <br /> TYPE OF WELL INSTALLATION TYPE CObWRUCT1ON SPCr' <br /> ❑M.ONITORING IFIL TIOII <br /> ❑HOLLOW STEM DIA.OFSCREHKXE / • ❑MULTIPLE CASINGS❑MULTq eVEL <br /> 11 EXTRACTION ❑AIR IAMMERrDRIVEN CASING THICKNESS WELL CASING DIA: <br /> sGKAPOk TYPE OF CASING:❑STEEL 13 PVC U'OTHER <br /> ❑.AIlt A <br /> U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE To BE USED El AUGERS U HOSE <br /> SPARGE/OZONE R'RJSH POINT(GPORCPT)_ GROUT SEAL PUMPED:O Yes O No(NOTE:MALXM400 FREE•fALL DEPTH IS 30') <br /> ❑SOIL.BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER; APPROX.BORING DEPTH CD �1 <br /> COMMENTS:�- CANDUCTOR CASI G PRO D O BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> (a TES,W �. ) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <br /> 48 WORKING FLOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby carttfy that I have prepared this application and that the work Witt be done I accordance with San Joaquin County ONlmaneas,Rules and <br /> RetiMfstiorts;and all appl e E)Nor is Laws. <br /> Signed /+ <br /> TiUelCompanY 'a t ea lg a�& zzhe rlm I <br /> I'dnC flame L.,, � <br /> ' RT NT ONLY <br /> L p 66 <br /> SITE MAP IN UNIT NFII.E,Aoof2Ess; DEP <br /> WORK PLAN.:DATED: Q O <br /> APPUCATWN ACCEPTED BY <br /> GROUT INSPECTION BY <br /> DATE ISSUED —I d SIO AREA <br /> - FINAL INSPECTION BY <br /> DESTRUGTTON INSPEUTION BY <br /> DATE DATE <br /> COMMEWWCONEIMONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECW BY DATE <br /> 0 5 PERMITI5ERVIGE# INVOICE <br /> c 57 WE -WAIVER C57 LETTER f7F AUTFiORIZATQN 70 SIG RMT O <br /> EHO20-e,1 TW&09 ENCROACHMENT DOC <br /> _. WELL PERIBTA. <br /> FILE COPY <br />