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i HU COPY <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> K' 600 East Main Street, Stockton, CA 95202-3029 SITE <br /> Telephone:(209)46&3449 Fair:(209)48&3433 Web:wKay.sjgov.oraJehd MITIGATION <br /> UNIT IV <br /> WELL PERMIT APPLICATION O <br /> NON-REFUNDABLE PERMIT EXPIRESS 1 YEAR FROM DATE ISSUED ! i <br /> ppiicatlon is hereby made in San Joaquin County for a pemNf to wnsbuet andw install tM work des*ibed, Tics al)Pkration a made in compliance wim Sar, <br /> oagwn County DeveWpmam Tito,chapter 9-5] t 5.3 and ft Standards of Sa�n,,,Lbequhl C=Ity,E(Mronmental Hearth Do artmeM, <br /> Well Loutbn� d� N!. �r�S Sir �J� 7.� k}[bs ,�,y Asseas°r's ?--Ow <br /> ..,, _ _— <br /> JJJ llJ t CA <br /> t ZI �?t` '� <br /> Own" �W D� <br /> ZIP ParcelX w� p <br /> Owner Addr J�/�N Zip G X20/PAorre <br /> C-57 Contractor C�C�Y _)cka _ Address'433 UXSf Co ll - City SQlltzl P--oSa uc>!t 0�-Siranprre���v�)SEE-G <br /> v 5a,���y� <br /> Comrutant'SobC AddreS$IZ43' OaK attDCtVE'. CtyCyrleord LicB-'�" �`^'H+ �-f29• Ss5s <br /> GIS CooNinates:X 38. 1 t .Y-121.39 z .Tow ship Range Section <br /> RK TO 8E PERFORMED: <br /> NEW WELLIBORING(CPT.GEOPROSE.HYDROPUNCK KkND-AUGER OTH6tT) 11 DESTRUCTION(CHOOSE TYPE BELOW) <br /> CI SOIL �� E)OVER-BORE DIAMETER <br /> ❑'OTHER ©PRESSURE GROUT <br /> N GROUT SPECIFiCATiONS <br /> COMMENTS2ltS woCi+),A P-ow o\ abo tkc- 4 zigp- <br /> TYPE S1I�t,,Q <br /> . <br /> OF WELL INSTALLATION T'�P CONSTRLw-rrr+u canCIFK:Ajl�ly� 1 <br /> OMONITORING >`IOLLDWSTEM DW W ,OF BOREHOLE 1 n 0MULTIPLECASINGSOMULM-LEVEL WELL CASING DLI r <br /> X1 MM TRACTICN ❑AIR HAMMERIDRIVEN CASING TH *SS TYPE OF CASING:O STEEL)(PVC O OTHER <br /> ❑VAPOR ❑MUD ROTARY OEPTH OF GROUT SEAL :30' <br /> TREMIE TYPE TO BE uSEDXAUGERS❑HOSE <br /> ❑AIR SPARGEIOZONE ❑PUSH POINT IGP OR CPT)_-GROUT SEAL PUMPED:❑Yes ANO(NOTE:/MA)UM`UM FREE-FALL EPTH IS ao') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS _ /�Z �/(,P,� <br /> [}OTHER. ❑OTHER. APPROX.BORLNG DEPTH �Oi XBOLTED TRAFFIC BOX OR ❑STOV'c PIPE <br /> OorwuerOR CADN PROPD$f p (a ym w +o o l <br /> COMMENTS' __ w�'+nm<nm�emem <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FINN iN #ffC-nONS <br /> 1 hereby certify that I ha4E prepared this application and that the work wtl be dorm I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, nd allaPP6 b!a alitornk Lawes. <br /> signedr '.'P� d r& 6"& C�*ae &ky�S <br /> Print Name ,% f 6a ' k60 `- <br /> Wte <br /> /^ �J DEPARTMENT USE ONLY kJ / Z9 S 7 <br /> SITE MAP IN UNIT N FILE,ADDRESS: a/ T IAI �g (�Q,r��` <br /> : .( v1 <br /> v4AC-101610e04_U-17— <br /> WORK <br /> sTWORK PLAN DATED <br /> APPLICATION ACCEPTED Y 4 ) AREA ._eIrY' <br /> GROUT INSPECTION BY Q FINAL INSPECTION BY- DATE 4410O <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDTTIONS: <br /> ACCOUNTING ONLY AID FAC* <br /> PE CODES .FEE INFO AMT RE;;WFD CHECK f REWO BY I DATE PERMIT75ERVICE a INVOICE <br /> �o -Z-DY' R#Q S <br /> C-57 WC -WAIVER C57 LETTER OF ALTrHORIZA TOSIGN PERMIT ENCROACHMENT <br /> kpV <br /> - � � 9 FILE COPY <br />