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• • FILE COPY <br /> d;P4�lN,• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> ,. Telephone:(209)468-3454 Fax:(209)468-3433 Web:www siaov oro/ehd <br /> k' UNIT IV <br /> WELL PERMIT APPLICATION �1 <br /> NON-REFUNDA_F1i- P RM(T EXPIRES 1 YEAR FROM DATETEISSUED <br /> Application Is heraltymade-to San Joaquin County for a Permit to construct and/or Install the work described. This applicatlon Is made In compliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and they�tandaMs of San Joaquin County Environmental Health Department. <br /> / // .,�- c;C;e Are. � Assessors <br /> Well Location €.a'A �Cna J^� Cross Street ag..' h/o/1 0e. City fj/iO o Zip '?S- Parcel#097- V/0- 7% <br /> p rty/_.,�taa 0a -Ies LTD T-- <br /> OwnerQp0'1C73'y+--- �/ �• Address ?7V (inrng �/1Ci .&y- city S��eGl��i�-i�.�" Zip sw7 Phone#2jw_t-?9-P2CM <br /> C-5T Contractor 17'C1-/}.bt/+rCM!n/Address //3.SO /'&;ae 10q k�Cfty.PA,rtAo�ei�i✓a Zip 7Sr c# J(�,Q Phon <br /> CensultanVSub Cnlr 4, bl,S Address. o qxe/lSl-/I F!� city = er ',' L;c# Phone 9G-bs2_9s'40 <br /> cls Cocrdlnarea X b lZ Y -121.323 TownsNp Range Section <br /> IN01W TO BE PERFORMED: <br /> [ EW^WELUBORING(CPT,GEOPHOBE HYDROPUhRANO-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# 2 (S C�-Z S6-2 ) <br /> .D WELL# ❑OVER-BORE DIAMETER <br /> 0*OTHER ❑PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> O EXPLOSIVES DETONATING-CARD — <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATKTN TYPE CONSTRUCTION SPF OCATIONS <br /> 0 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE /v ❑MULTIPLE CASINGS O MVLTH.EVEL WELLCASING DIA;_ <br /> EXTRACTION ❑AIR.HAMMERIDRIVEN CASING THICKNESS TYPE OF CASINr1 O STEEL O PVC O OTHER _ <br /> 'Qa7APOR11 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED O AUGERS O HOSE <br /> AIR SPARGEfOZONE fikPUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUNI FREE-FALL DEPTH IS 30') <br /> OISOIL BORING ❑HAND AUGER GROUT'SPECIFICATKDNS _ <br /> OTHER. ❑OTHER: APPROX.BORING DEPTH Lo ❑BOLTED TRAFFIC SOX OR O.STOVE PIPE <br /> CONDUGTOR CA5tli0 PRgPOSEO (K YEa,ist om* I <br /> COMMENTS Tc..,�m .Svr'! .�sr:..nc ..,�// 6. 4.ba=:a�w.cd r oar` <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I WrAbY CW WY Dret.1 have prepared this apptloatWn and that the work.will be done I accordance with San Joaquin County OrAnances,Rules and <br /> Rayutaifous,artasWicabli.Califonnia Laws. <br /> Signed Gr�` Title/ComPanY 1Y .'rn GGICI'.rY'f /il�C Zri�Eyl S' (22 <br /> Point Nene <br /> DEPARTMENT <br /> LySITE MPP iN UNn'IV FILE,ADDRESS:WORK PLAN LUSTED: 9 r / jAPPllCAT90N ACCEPTED BY DATEWUED U `!o'/0 AREA Ot7GROUT INSPECTION BY CTION BY <br /> DATE <br /> DESTRUCTION INSPECTION BY DATE V <br /> COM�¢EI' TSICONDITIONS: <br /> ACCOUNTINGONLY: AIDAI FAC# <br /> PE-CODES F.EEINFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE:# j INVOICE ' <br /> LA <br /> s S 9i3 <br /> G57M V -WAIVER =NM C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC Affif <br /> EHD29411.1ot1809 WELL PERMIT XF <br />