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FILE COPY <br /> l SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street Stockton, CA 95202-3029 MITIGATION <br /> •. •• Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.s1oov.OrG/ehd UNIT IV <br /> WELL PERMIT APPLICATION �^ <br /> NON-NON-REFUNDABLE FUNDAE PESMIT EXPIRES 1 YEAR I "DATE ISSUED O� W 5 <br /> Apo6caticn Is hereby made to San Joaquin County Por a permit to construct andlor Install On work described. This application is made in candlalce with Sen <br /> Joaquin CaKKY Derebprnem TWO.chapter 8-1115.3 and Bre Standards of San Joaquin County ErMrorueerdal HOMO Depwbn*nL <br /> Assessors <br /> WaIlLocation 1717 5. Center St. Cross Street W 3rd St. CRY Stockton Zip 95206 Parcel Parki no Lane <br /> Prapry <br /> Omer City of Sfnr4fnn MNeas 21 E. Weber Ave. City Stockton Zip 95202 Phone a 209-937-8366 <br /> C-57 Conwace, Gregg Drilling Add+ese 950 Hone Road City Martinez Zip 94533LIcC 7485165 9P25-3e13-5800 <br /> ConeWNntl6ub Cow PSC Adtreas 210 p. Sand Bank Rd. City Ce l urebfa DCB Phone 618-291-1543 <br /> GIS Coordhweae X 37.93 ,Y -121.28 ,Township IN Ramp 6E Section 14 <br /> WORK TO BE PERFORl1ED: <br /> 13 NEW WELLIBORINO(VT,GEOPROmc HVOROPuNcK HAND-AUGER,OTNEW) 0 DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑WELLBORRK;% CPT-3 [I OVER-BORE DIAMETER <br /> O PRESSURE GROUT <br /> 0lar"ER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE 2e 0 NIULTIPLE CASINGS 0 MULTILEVEL WELL CASING DIA_ <br /> O EXTRACTION 0 MR IMMERARNEN CASING THICKNESS TYPE OF CASING:O STEEL 0 PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEX T.D. TRiBOE TYPE TO BE USED 0 AUGERS 0 HOSE ( . <br /> 0 AIR SPARGMZONE 13 PUS/POINT(GP OR CPT)_GROUT SEAL PuIAPIED-,jjYaf 0 No (NOTE:MA)OMUM FREE-FALL DEPTH IS 30') V` <br /> 0 SOL BORING 0HMD AUGER GROUT SPECIFICATIONS Neat Lamont <br /> 0 OTHER: 0 OTHER: APPROX NORING DEPTH 55-90' 0 BOLTED TRAFFIC BOK OR 0 STOVE PPE <br /> cormuCtan r.{aaa3 raDftMeJ-per RwLre WaalWlbun wrWua rraaH <br /> COMMENTS: 1 CPT boring and uo to 3 hvd roounch bort nos mA , t.. 3 ...iX hp.t.L9. <br /> NOTE OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMffS <br /> 4E W101710NG HOUR!NOTICE RECIUMM FOR INSPECTIONG <br /> I hereby coney I he",13,1111 Sita application and But rhe work will be dorsi 1 eccardenw With Sen Joaquin Couray Ordinance.,Ruin and <br /> Rayrdatlona, aate�//Ful1aa Lalee. <br /> Spnsd c (Y Twacum"vy Project Manager <br /> PM1d Name Paul Anderson D I gel, Zo/O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE.AGGRESS. /7/7 ;5;- <br /> G• 54A--WORK PIAN DATED:_ //- Z 0 9 <br /> APPLICATION ACCEPTED BY LS� GATE ISSUED IMAREA <br /> GROAT INSPECTION BY FINAL INSPECTION BY ' ` •:'A DATE <br /> _ <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID 1 FAC e <br /> PE CODES I FEE IWO AMT RENTTED CHECK It RECV'D BY DATE PmtmmsERVICE a INVOICE <br /> 0 I-8'- O R# <br /> C•57 WC -WAIVER R OF AUTHORIZATION TO SIGN PERMT V Emµ �[ <br /> END 2941 10(2509 X i13( PE o A4-/3s O <br /> FILE COPY <br />