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�,�+s,u' �r.•.� SAN .JOAQUIN COUNTY <br />�;';., ,," '„.' . •:7, ENVIRONMENTAL HEALTH DEPARTMENT SITE <br />IV�ITIGATION <br />600 East Mein Street, Stockton, CA 95202-3029 <br />Telephone: (209) 466-3449 Fax: (209) 468-3433 Web: www.siaoV.orale�h4 UNIT IV <br />WELL PERMIT APPLICATION - <br />NUN -REFUNDABLE PERMIT EXPIRES 1 YEAR FRbM DATE ISSVED <br />Application Is hereby made to San Joaquin County for a permit to construct and/or iwaii the work dotterib8d. This appllcaun is made, lr}ot�IlArics with San <br />Joaquin Courcy InPvPtoCmam Tllle. chapter 5.1115 9nd the Standards of San Joaquin County Environmenial Health Depannner�i�[„' <br />(�.(orn.,t GIy'crossss trust Va for'4o ph,iX� city 7!4� _zlp'f�3//., parcel ii, y02933 <br />Well Location_:. <br />property ����� "1 <br />Owner ��I ��CJda �0 fr Addrecb T Orr +r �: Z-73 City Vim, .. i S PC MK zip qS SX.S Phones Z°9�6ICJ' �6y <br />p� .7 <br />dress 1r 0 ByRaAd City c+7Ip yS6'3 LlcN `I S/bsPhone <br />%,_Q, contractor <br />Conxutm �_ �`�t a_ Address ,.Sq�t tLP1 LIS. �' � A_ CItY �. Lic u.�� Phone SIO -Y20 - s � 71 <br />Sub Cntr <br />- — <br />�FsSa • <br />GIS Coordinates. X Y TOWnsltip _„ ,-. __ Range ___ Section —_ <br />WORK TO 61 P ED: <br />[NEW o ”' RIN E MOPROS I•tvQyr,'OI�UNCH. HAND,AUGEH,OTHER•) I] DESTRUCTION (CHOOSE TYPE BELOW) — <br />$OIL BU ING'I(�,�, - �.,6�,�.., __._.._.. ❑ OVER -BORE DIANIFTCR <br />" ❑ PRESSURE GROUT <br />1NELL rl__...---—_._..-. <br />- GROUT SPECIFICATIONS <br />9*10THER <br />COMMENTS�!S.C;r � <br />..__... . ' / <br />TYPE OF&( 6 <br />❑ MONITORING <br />❑ EXTRACTION <br />❑ VAPCR <br />Q AIR SPARGE)OZONG <br />'%�SOI L BOR ING <br />❑ 07Ht'R _--.. ... - <br />INST6t TIC! TYPE CONSTRWCTIQN SPECIFIGATi� <br />❑ HOLLOW STEM DIA, OF BOREHOLE '7 r -H^ ❑ WATIPLF. CASINGS Q MUL7N.EVEL WELL CASING DIA:., — <br />❑ AIH HAMMER/ORIVEN CASINO THICKNE-68 . �.... TYPE OF CASING; Q S1 EEL ❑ PVC 0 OTHER,— <br />❑ MUD I401ARY ., DEPTH OF GROUT SEAL -#iD bCAaL_ TREMIF YPE TO DE USED ❑ AUGERS Q HOSE <br />�T <br />'M PUSh1 POINT (QP OR CPT) „P• GROUT SEAL. PUMPED p Yoa L&No (NOTE: MAXIMUM FREE --FALL/_ DEPTH 15 30') <br />d NAND AUCGEK _- „_ GROUT SPECt`ICP.TIONS 6or ��1.4 ✓� L4U v=f- 0 �% iradc <br />❑ OTHER. APPROX BORING U~ <br />P rH O BOLTED TRAFFIC I= OR D 570 PIPE <br />CONDUCTOR CA vaoaosI• vat. <br />nn ryrinlb(l00ASiCIiv) <br />COMMENTS!___—__ _._ _.,..... <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR }NSPECTIONS <br />Hereby certWprre have,Ica n d that the work will De done Iaccordance with San Joaquin County Ordinances, Rules and <br />Regulationsw SignedTitlelCompenY Print NameDate 1_. . <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS' __ _ Z.: �_ .... �q.�-• ' "^� <br />WORK PLAN DATED <br />APPLICATION ACCEPTED BY Imo{ [)ATG ISSUED 4jle k AREA „_ <br />GROUT INSPECTION BY FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY <br />PE CODES FEE INFO <br />AID R _ <br />AMT REMITTED <br />1 iso I I L -$ S1,°° <br />C 57 Z , _ WC .. .._ WAIVER <br />F.HUiYC} 11I$1C7 <br />AT <br />CHECK P RECV D BY DATE PERMIT/SERVICE p INVOICE <br />1d3(3/o SR# 1§Iggo <br />:87 LETTER OF AUTHORIZATION TO SIGN PERMIT —•.. ___ ENCROACHMENT DOC _— <br />WEt.I RNT APP <br />(Z(i� ooJy�4 �� <br />