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9 0 <br /> 0.0 "1N• p 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:wuuw.s ov.or /ehd <br /> •.�. P�� A ( ) ( ) i9 9 UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Develo ment Title,chapter 31115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 282.471;5 WESTAssessor's <br /> Well Location WAS 111N4TW STWi� Cross Street MaVq PI'Z(4olur) city STOLkTIM zip 95103 Parceltt 0200 <br /> Property <br /> Owner HIVE _ Address 20100 W/kTE00-1uVyN City�w0.NKEIAZip I 36 phone# 262 <br /> �99.9b.VD <br /> C-57Contractor Address 11350 ilillIRNnWIE City (b4urt ZipG592Uc _oSbfPhon,"" <br /> 3 <br /> 0010 <br /> ConsultanHSub Cntr E-M-Wytf T1l(- Address 25ZS N(141WIJ LWK D✓ONO city STgY4 ✓`I-fp Lie# NA Phone_tIb.9LY•R3?3 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE P ED: <br /> 5(NEWWEL ORING CPT,GEOPROEHYDROPUNCH,HAND•AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL 56-Z.o ttiRa/414 5a-29 ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑"OTHER GROUT SPECIFICATIONS <br /> H1u+n?, 2 a for l [I EXPLOSIVES DETONATING <br /> �CARD <br /> COMMENTS � dfqjN <br /> s ' dr r rN011 w{Y 11 <br /> Wi reJ ✓ . N0 t•. le lm o GW sjwrs <br /> r0 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �/ <br /> ❑MONITORING D HOLLOW STEM DIA,OF BOREHOLE Z 11 D MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: fy A <br /> ❑EXTRACTION XAIR HAMME<� CASING THICKNESS N A•� TYPE OF CASING:O STEEL D PVC 0 OTHER �_ <br /> D VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL�� THEME TYPE TO BE USED❑AUGERS❑HOSE <br /> ��❑l AIR SPARGEIOZONE D PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:D Yes*No (NOTE:MAXIMUM FREE-FALL DEPTH <br /> �IS,.,30) <br /> y�ISOiL BORING ❑HAND AUGER GROUT SPECIFICATIONS 501110f w)lL 6c-' CfeeII 11 TD /TRr`A TS]01L <br /> ❑`OTHER: ❑OTHER: APPROX.BORING DEPTH 7' t ")( ❑BOLTED TRAFFI vBOX OR ❑SCOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES.list spe6f bans in cpmnant section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify tt at I haveJir rgd•fffis application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a II a e B" r(ornto Laws. /' 11 1 L <br /> ce"Il7)Vaw-C°Jl TWC <br /> Signed Title/Company F— <br /> , <br /> Print Name Ve f4e Dale ZI A'"' 7-W C, <br /> DEPARTMENT USE ONLY ( L/ Qty. �( <br /> SITE MAP IN UNIT IV FILE,ADDRESS:dM L✓,_ C[JQ��•— C + *' C`ft.lT 0•� 26-3T� <br /> WORK PLAN DATED: /ho - J <br /> APPLICATION ACCEPTED B,Y,/�- A�-11�r,y [n <br /> DATE ISSUED �M ID AREA ff z. <br /> GROUT INSPECTION BY /d•(�^"r-"� FINAL INSPECTION BY S /U DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: &PYU4 ..0 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# CC RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> oy 0430 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PE IT ENCROACHMENT DOC <br /> EHD 29-Of 10128109 WELL PERMIT APP <br />