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• • FILE COPY <br /> Q SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> slrE <br /> 600 last Main Street,Stockton CA 95202-3029 <br /> Telephone:(209)468.3449 Fax,(209)468-3433 Web.www.sigov.oralehd MITIGATION <br /> � UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERAMT EXPIRES 1 YEAR FROM DATE ISSUED �t.P(J <br /> Application is heraoy made to San Joaquin CAunty for a permit to COnshud antllor Install!the work described. This applications made in iartCa with Sen <br /> Joaquin Coctnty!Dttevelopment Tale,,c-ha_pterr&Y 115.3 aM-t�*Standards M San bal�ain Cumly Environmental Health DepaRment. C� <br /> Well LocaftW247A CuplN I?001 rr oou SStreefDr�x�LA±0/tl IZOOLI Cay \ Z1p P r(7�W's r0JJ20Zq <br /> P <br /> POM <br /> Ower <br /> &44amss ./ Ul�d�yyd .. City <br /> zip 4b0 <br /> C-57 C"bavor C,I, ( C r'� Addr"srL83 ��a1jeP P,I—- Cqv SR✓Yh'.Fw4 Lic*T�:kp�tcq-WbB-('095 <br /> com muni suh c VIj <br /> Addiess_t'?S3OaK_ i00 DnVt' city CZC)WA _ Lic a�Phone( 29- S5S5 <br /> GIS Coordlnauls:X 38. 1 Y --{?-A.3cf 3 •TOWW* Rattpe _Section <br /> RK TO IE PERFORMELI: <br /> NEW WELLMORING(CVT.GEOPROBE,HYDROPUNCH,FIAND-AUGER,OSHFR') Q DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL SORT Cs ❑OVER-BORE DIAMETER <br /> 'Q'WELL f_TyW­1 O ❑PRESSURE GROUT <br /> ❑•OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPg OF WELL INSTALLATION TYPE <br /> n <br /> Q MONITORING XHOLLOW STEAL DU.OF BOREHOLE Orr ❑MULTIPLE CASINGS O MOLT)-LEVEL/ wELL CASING GIA, 4 <br /> XEXTRACTIDN Q AIR HAMMERIDRIVEN CASING THICYMSS TYPE OF CASING:Q STEELXPVC O OTHER „_ <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 3+ <br /> TREMIE TYPE TO BE USED)<ALIGER$Q HOSE <br /> Q AIR SPARGEiOZONE Q PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:O Yee wb(NOTE MAXBMUM FREE-FALL DEPTH IS 30') <br /> O SOIL BORING O HAND AUGER GROUT SPEgFICATtONS <br /> r� t �/ <br /> Q OYHER Q OTFlER. APPROX.BORING DEPTH .pe BOLTED TRAFFIC BOX OR Q STOVE PIPE <br /> - <br /> COMMENTSCONDUCTOR CA81N0PROPOSEO YES.vet ePeaRaeons imnxnent reartv+) <br /> : <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby cwttfY that t have PraPared this application and that the work will be done I accordanq whh San Joaquin Courdy Ordinance,Ruies and <br /> Regulations,a all appi" 1Hom1411 Laws. ((� 4t ,,,,LL,�,,,,,, <br /> signed '� Ti1k7CanpvtyTTT 172D 1" CACS soQi1dNS <br /> Pnm Nam Date_ <br /> DEPARTMEMI U§E ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: r Q <br /> APPLICATION ACCEPTED BY DA ,,roe <br /> GROUT INSPECTION BY 9u � (y <br /> FINAL INBPEC'TtON <br /> BY <br /> i DATE_ d" <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING OWN> AID} FAC0 <br /> PE CODES .FEE INFO AMT REMITTED CHECK a RECM BY DATE PERMITMERME i INVOICE <br /> 290 �9• zoo <br /> G57 V,/C -WAIVER C57 L R OF AUTHOR2ATION TO SIGN PERMIT v EN MENT DOC B� <br /> EMl rias n5A>{NE6) <br /> WEtI Rw A �� <br />