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����o� cJ • ELLE COPY <br /> MAY 2 1 20 SAN JOAQUIN COUNTY <br /> n. VIRONMENTAL HEALTH DEPARTMENT SITE <br /> ,. ENVIRONMENT HLq%Crpast Main Street, Stockton, CA 95202-3029 MITIGATION <br /> PERM 468-3449 Fax.(209)466-3433 Web:wwW.slaov.ora/ehd 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 andlor Install the work described. This applIcation Is made In compliance with San <br /> Joaquin County Development Title,chapter 0.1115.3 and the Standards of Sen Joaquin County Environmental Health Department. <br /> W0111-ocation 2303 Wecf la„e e Cross Street klrne <br /> e ,. Assesses <br /> �A� City -'TSI—`la•+ Zip zo5 Parcalt l D`1O.1--7Property d <br /> Owner AA-116 _�hornl*-% Adtlresa al-716 k. ftUI4 kcl- City . o Zip pg3--Ub Phcne0 / 2d2Z- <br /> C-57 Contractor Assess,>Z38QP5f ,city, , �..� Q uor-/�roPi/Pho�_53,ei' / 3198 / <br /> c / <br /> ConaultanNSub Cntr_IG�E/ Tf(-}� Address 35, &de, krae City PlA�_ Uc0 — PhonelD9 6,99-APPLE <br /> GIS Coordinatao:X 3t • 1 T 0 ,Y _�-I”` - ?'d �� ,T,wnsNP Range Section <br /> WORK TO BE PERFORMED: <br /> 91 NEW WELLBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> 6f1SOIL BORINGO l,�1 ❑OVER-BORE DIAMETER <br /> ❑WELL* ^ ❑PRESSURE GROUT <br /> ❑'OTHER--��pp�� ��/�JO GRROUT SPE91 TIONSrt�a _ <br /> COMMENTS: S (yblp,� &f✓ <br /> TYPE OF WE" <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 0 <br /> ❑MONITORING 0 HOLLOW STEM DIA OF BOREHOLE — 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING OW— <br /> D EXTRACTION D AIR HANMER/DRrVEN CASING THICKNESS TYPE OF CASING:0 STEELCI PVC D OTHER 1� <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL—THEME TYPE TO BE USED D AUGERS❑HOSE Irl` <br /> O AIR SPARGE/OZONE 14 PUSH POINT(OP OR CPT)_GROUT SEAL PUMPED:O Yea D No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') \ <br /> ,SOIL BORING 1Sit HAND AUGER GROUT SPECIFICATIONS <br /> OTHER�K W 0 OTHER: APPROX BORING DEPTHD BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONWCTOR CASINO PRQP o Bi YEa.W tpatlaru.h.1 mean) <br /> COMMENTS: G <br /> NOTE: OFFSITE E1RINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have proparod this application and that the work will be done I accordance wlth San Joaquin County Ordinances,Ruloa and <br /> Regulations,and all applicable California Laws. <br /> Signed ,�.�.. (I/�.rY�-tl ntieicompanys[.gre r-tl'rta e2'4' F+7 rlCtnesr� F-- .-�• <br /> Pam Name iyt,.„ "%h, Q,b.yv Date6.It6-o9 R.III eveloP44 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: a30 <br /> WORK PLAN DATED: OU D <br /> APPLICATION ACCEPTED BY AED <br /> (� <br /> EA <br /> � <br /> GROUT INSPECTION BY FINAL I PECTION BY q7E/ <br /> DESTRUCTION INSPECTION BY DATE TT <br /> COMMENTSICON D ITION S: <br /> ACCOUNTINGONLY: AIDS FAC0 <br /> PE CODES FEE INFO AMT REMITTED CHECK* RECV'D BY DATE pEJ7MITBERVICE fl INVOICE <br /> y Zd C- 2t W57313 <br /> C•Er INC -WAIVER CS7 LETTER OF AUTHORIZATION TO SIGN PERMIT 14 ENCROACHMENT DOC <br /> EM02001 11,Sor Mme) WELL PERMIT APP <br />