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R <br /> _y't • • -FILE COPY <br /> Y RSAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT — <br /> K 600 East Main Street, Stockton, CA 95202-3029 SITE <br /> MITIGATION <br /> Telephone:(2D9)468-3454 Fax:(209)468-3433 Web:www siaov OM19hd <br /> ` ( UNIT IV <br /> WELL PERMIT APPLICATION % <br /> NON-REFUNDARLF PFRMIT EXPIRES 1 Y AR FROM DAT ICSU n ��i�"' <br /> Application Is hereby made to San Joaquin County for a Permit to construct and/or install the work described. This application Is meds in Com`CRIauCe wth San <br /> Joaquin County Development Tide,chapter&1115.3 and the standards o/San Joaquin County Environmental Health Department. <br /> Well LOcatior._�f)� 1:• "P"F' U�• _..as Sir.$, AW± 1 ASssasorn <br /> Property ata Sr City S'R)4r�nJ ZIP <br /> qUR - Parcel0 113H3og0 <br /> Owner r 171 Address C12"l- AlcoAa, rd city 6�N4 Pow-m zip r(4S85 Phone# <br /> C-S)Contractor mea <br /> 11riLi— AddressSAD �_J���+r�g City -}WMOCA' ZIPq sLIcM 2633 ZC p� -hyo <br /> Consultant/Sub Cntr,�nlJ''t�C. Addrees.?rOj' • kdt` 2e fJ 54102 City p" Lica: ^Phone 2L &bl Okkp <br /> GIS Coordinalos:X 37.965011 Y -121.258205 ,Township #Range Section <br /> �V•ORK TO BE PERFORMED: <br /> I�Q NEW WELL/80RING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> Q SOIL BORIN(3Y <br /> WELL N ❑OVER-BORE DIAMETER <br /> •OTHER D PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> ❑EXPLOSIVES DETONATING CARD <br /> \�vn <br /> "V <br /> TYPF�LL INSTALLATION TYP <br /> ----.—._� CONSTRUCTION g�IFICATiOFIAfl �l � <br /> MONITORING KHOLLOWSTEM DIA.OFSOREHGLE 6_ D MULTIPLE CASINGS D MULTI{EVEL WELLCASINGDIA2L �t <br /> D EXTRACTION D AIR HAMMeRIORIVEN CASING THICKNESS•f(O Ke 9Mk TYPE OF CASINO:D STEEL JM PVC D OTHER <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL O�•4Y TREMIE TYPE 70 BE USED,Q AUGERS D HOSE \1\ <br /> D AIR SPARGUOZONE D PUSH POINT(GP OR CPt)_GROUT SEAL PUMPER 19 Yea D No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> 11 SOIL BORING 0HANDAUGER GROUT SPECIFICATIONS +A�.r�Da r�l�/jI��T `1- `\\ <br /> D OTHER. ` L, 4 ,(RhrG 1„ y^'�I <br /> ❑OTHER; APPROX.BORING DEPTH �L� �BOLTED TRAFFIC SOX OR DST PI E o•s <br /> COMMENTS: CONDUCTOR CAStNB PRORosro to YES.In tpsoFbso-n h eommbe brJbn) <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby cortify that 1 haw prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all appliub Cat I aws. / / / � <br /> Signed J `/ G• TM1IelCompany� / rL 6;' 0 P r <br /> /��/ <br /> Print Name l]t^/1 \hl Date /4 <br /> PEPARTMENT USE ONLY /� <br /> SITE MAP IN UNIT IV FILE.ADDRESS: Z E. DQ-�a- !-Deb 3 S?� <br /> Vv)RK PLAN DATED: l` /O .7' OP <br /> APPLICATION ACCEPTED BY DATE ISSUED 3-96 AREA 040 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID FAC0 <br /> PE CODES FEE INFO AMT REMITTED CHECK ft RECV'D BY DATE PERMITI8ERVICEA INVOICE <br /> 70$ -r`" 3-is-lo R# Q <br /> C-57itWC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT EUCA9AElHdENT D <br /> EHDz 01 IO28D0 - WELL MIT APP <br />