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JUI ZV 2e1i 3 11:55 28946EIN3 FIFTH FLOOR • PAGE E2 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT(END) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468.3449 <br /> NON•REFtIN DABLE PERMrr I7 IMS 1 YE4e FROM 11AT81lr1a1�D -I <br /> Application:s hembymade tD San Joaquin County fora permd to twnstruet andlpf install the vrork daaedhad. This applloation is madee in rontplian04 with San <br /> Joaquin County Development Tlda,Chapter 81115.3 and the Standards offt Joagbin County Envlronmanatl HeelM DapennItm. <br /> WELL Location 3.I79'7 4r"/ Reae� crm weal e'YY/ fi e a �.,rTl� Aesesso<a <br /> PROPERTY Omer.F'rciaruicSA�c� addreas�.0, &fix `!Sra? <br /> 6kp(V"40o 4 z•P Pien¢x /l9-cI3%-82rf7 <br /> C47 CCntraobr_Gaue nvic fS Addms ire;c 7 ..t-._,_:_I .r clty��Zjp 5//2,LI�111%'Pham# fCg.g 0 •.4 .. <br /> 77-7 <br /> ConsuTtantISub eono-aaorJ2 'NeEn�S Addreea7770 kealee LN Q'fAC, aklawo( <br /> "�I--�— b n��,_Pnons►'.S/0-636'$;�'CC) <br /> GIS Coordinacasr X.. .Y .Tavnahip _ Range ___$aCaon <br /> K TO a►aaPnRMan; <br /> EW WELL r BORING I CPT,QEOPROIh HYDROPUNCH•HAND-AUGER.OTHER") p DESTRUCTION(choose We trolav) <br /> WELLa_5-34901L GORING 00 OvexisoRE <br /> 9•PS S-I,�- 91PRESSUREGROUT <br /> *Other: GrDue Spadfaatlons: -r7---�— <br /> CO S 1 nS /1 4 JA'7oN� M /,1,6 eA GA4WJ*j L0 77 /U•iS <br /> illint to,be nl�5 -vU[R STCJ Vi - �� Cr"�•'•—•-- <br /> TYPE OF WELL IN9T LLa E QQMl11NCT ON 5PECPICATIONa <br /> MONITORING P(AOLLOW STEM DIA.OP 00R8N a MVL-nPLE CASINGS?p YES IKNO WHU.CASINGDu1:__ <br /> tl EXTRACTION bAURHAMMER/DRIVEN CASING THICKNE88 '' TYPE OF CASING: 0ar[kL dPVr: 0OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT S-aA4 _ TREMIE TYPE TO 6E U$ED: d AUGERS p HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yea 0 No (NOTIi: (MUM F•p��E-FALL DEPTH IS 3or) <br /> I]80I aoFUNG DHAND AUGER GROUT SPIC7FI0ATIONS L MIN�� M*47 <br /> 0 OTHER: n OTHER APPRQX BORING DEPTH ji0 L <ao-T FtC a0 or 0 STOVE PIPS <br /> CONDUCTOR CASINO rROPOSEDv I if YES,est speuticaUone nera):_1_ <br /> •COMMENT& <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Ordil ¢es,Rules and"Ill Io p and all applicable Cidifornia State Laws. <br /> Signed <br /> Print Name Q DE O&W USE ONLY Date_(((��__.-L!L_w��67 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED- (I)jk1t )6L - 1 <br /> Acplioption Accepted BY /j Lml -� Dela t"wea <br /> Grout Inspedlon By Date Final Itupaalon ay <br /> Der volion Inspecton By Date <br /> COMMENTS/CONpR/ONe: _ j <br /> ACCOUNTINOONLY: AID# cnrr J <br /> PE CODES FEE IMPO AMOUNT RdMn7ED CHECK0 RXC'a By FA PERMIT 16ERYICE REQVEaTM MVO!CR <br /> ;. V v"j' I` ! &A ORN <br /> C"57_ WC_ WAIVED_ C-57 Letter of Authorization to 919n permit_Erkrodchment dor._ <br /> ZO 39Vd -nvooW 3Dfl68 91£899£813h TT:9T h©©Z/ZT/T© <br />