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W <br /> San Joaquin County <br /> Environmental Health Departme (� � - SITE <br /> � D600 East Main Street, Stockton, CA 95202-3 EX_ L It i MITIGATION <br /> --� � 209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org�ehd UNIT IV <br /> Well Permit Application �(� �Nf/aR 1 S1CL8 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE! / Qhh1EP.;j ll;/{�r�i <br /> Application is hereby made to San Joaquin County for ape 6 to construct and/or install the work describe I li4 it��Wti made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 rid Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location �0 n. 7 )//! Cross Stre r City Zip Parcel# <br /> PROPER U J l i�u ru I Wr✓/rt1 (� f rico ( 'C� UH o) <br /> Owner //// Address_i On ;( 1 k 4 City / Zip ( Phone# <br /> C-57 Contractor/? , 'V0,1 Addres l — / V11 Aity—%CUAZipy�dt none#,'�099�i+�-�3�1Sy <br /> Consultant/Sub Cntr Address Ciry Lic# Phone# <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> U NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') O DESTRUCTION (choose type below) <br /> n SOIL BORING# 0 OVER-BORE. DIAMETER <br /> n WELL# n PRESSURE GROUT <br /> XOther u" (s6 f GROUT SPECIFICATIONS_�1� <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPE IFICATIONS /� jA <br /> a MONITORING HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> -0-i <br /> EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: n STEEL kVC n OTHER: <br /> D VAPOR AUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS Q HOSE <br /> KiR'SPARGE)OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes ON NO -- __ Iy-— FREE=FA// DEPTWIS 30` <br /> `SOIL BO NG / 0 HAND AUGER GROUT SPECIFICATION�JVpa ( �L�/Hi/✓// ) <br /> THER: ie p OTHER APPROX.BORING DEPTH UoL�K(J I Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> �+ fr I ''7 <br /> CONDUCTOR CASING PROPPSED—�—�(if YES,list sp fications in comment se on) <br /> COMMENTS.& I PVC FrZpik. I VI O I n I aild Lk�,.^'/i�,n ryo !7 ✓re` R. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 4U WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances Rules and Re 11a <br /> VonsI and all applicable California State Laws. <br /> Signed x TitlrJCompany k <br /> r ? <br /> Print Name / Dat �1 <br /> KLEINFELDER INC -23((�& • L, 13224 <br /> STOCKTON PETTY CASH STI���S U i i- i U Li <br /> '�MAL <br /> PH.(209)948-1345 <br /> 2825 E.MYRTLE STREET <br /> STOCKTON,CA 95205 ���y�t.)� l�DATE 90-2267-1211 <br /> PAY I/ _ ... ... <br /> TO THE <br /> ORDER ry <br /> ORDER OF $; X� 00 <br /> per.. . <br /> O RS <br /> _ Wbank. <br /> jFiwsus,.�r.,rn d usbbank.coom y/ <br /> FOR l'/a P501�?Xe✓ w�JL 1/JLC F7 S lGL7 / V ©� nr <br /> 65013221.0 -1: 121122676,: 1S34909SW39Lo <br />