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FILE COPY <br /> -, SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 111111E 1110.. 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> ci�Qddg; Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.s1aov.or0/ehd UNIT IV <br /> WELL PERMIT APPLICATION T <br /> NON-REFUNDABLE PERMIT EXPIRES 1 R FR M DATE IS D w v X Z„ <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. is application is made in compliance with San <br /> Joaquin Cou Development Title,chapter 91115.3 and the Standards o„San tloaquin Counly Environ tal Health Department. <br /> pp�� ,�L / [1 Assessors !� <br /> Well Locallo� u0.50�/ .1 45644-eero s Street 0,1444 1yjryN, T c ._�-+7_-1 95�/ Parcel#Pro <br /> Owner HiQ NcYi�l/ It <br /> K I�w� s 7r/Z rte” >CAGITO.�fCib ��1 ANS�/1/J'i�/l.Jr2ip 'Phone#l'J.71/ yI��1/ <br /> C-57 Contractor ',I./y/I Address(}�Q�6cf,;4- �%B/W- city W��/ayfic� Lic# Phone 730:k "'o�7y/ <br /> Consultant/Sub Cntr '71.1-L-� Addree"u&Wd / Sr.'�ti�laty �> Uc# Phone5l0-yd67J3,3' <br /> GIS Coordinates:X T's { tsC ,Township Range '5 I?�_ Section 3 <br /> WORK TO BE PERFORMED: / <br /> ❑NEW WELLISORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPE BELL <br /> ❑SOIL BORING# ❑ VER-BORE DIAMETER `��'' <br /> ❑WELL# ❑PRESSURE GROUT n <br /> ❑'OTHER /,, �GROIJr SPECIFICATIONS 1l�V <br /> COMMENTS: �S'i/ LL/OI.IY,6If.,iGl �/!�//JialJ7�/i,Q���/',5 �/V/ <br /> vOl <br /> TYPE.OF WE INSTALLATION TYPE N T T N PE--TrIFI A I N it <br /> MONITORING HOLLOW STEM DIA,OF BOREHOLE O ❑MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: d' <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> C on / <br /> El VAPOR [I MUD ROTARY DEPTH OF G UT SEAL �'� TREMIE TYPE TO BE USED FI AUGERS�HOSE p\ <br /> ❑AIR SPARGEiOZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ANO (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') G <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS W I/ <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH — 3D, ?2Z6 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> - r CON <br /> NOTE: <br /> PROPOSED (HYES,IkGfmrommsecti <br /> I spowGsin enl m) <br /> COMMENTS: r n <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby cerllfy Ula[ have prepared th!j,application and that the work will be done I accordance with San Joaquin County Ordina ces,Rules and <br /> Regulations,a all applicable Ca ta'mia La�fv s. <br /> 62d �5 <br /> Signed TitlelCompany <br /> Print ame R ___. - __ - _—Date <br /> DEPARTMENT UpSE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ���� .5 -{ '-0 j, <br /> WORK PLAN DATED: Us 6 9 <br /> APPLICATION ACCEPTED BY DATE ISSUED 8' / 'U/ AREA O V01� <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 0 W ©R5 3 •23 R#0 <br /> C-57 WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT IFE//NNC/�R�O�ACCHMENT DOC <br /> ED2 11 11I5A1(wE0) �1I��—'-' I A <br /> FILE CO I <br />