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1,� uQuIJ !!: !b 1U`-'4683433 FIFTH FLOOR p.� <br /> 4 . ;CE 0? <br /> p <br /> WELL , ERMIT APPLICATION FOr,IM SITE <br /> SAN JOAQUIN COUNTY PU13LIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD UNIT IV <br /> 304 E. Weber, Third F'oor'`_;11_6tockton CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES YEAR FROM DATE ISSUED <br /> cpliGatien is Hereby made to San Jpacuin County for a permit up cen3 a and/or install the work desonbed. This ag; OpaHort rs mzde n:cprnpl@-rg with San <br /> :3cuin Ccunty,Development Title,Chapters-!115-3 and the Standards of San.;cagWrn Coen, pcb- a <br /> �-/ y he Health Serllces,Environmental Has.tt Civision, <br /> ELL Location �12.Ue.v.-f� .�T• Cross Siree[ Aesessor's <br /> (�' C;ty ICL zrp^ 37/ctarcel# <br /> ROPERTYOwnerm-tm t316-r-s Addmss `9I It A). <br /> CiH zip S37�ngonex�0�3 <br /> •57 ContraCpr�-11/.� (`- VRCA Address �� 5 C� city C U <br /> �tv:cRs �S- zi � L's7��P oe /6777-5° 00 <br /> ansult3nt r Sul Contractor�A�(1Q EnU'mnitl es3 f07G- IQFI� <br /> IS Coordinates:X Y .Tewnshlp �: P.ange Sec"on <br /> 'ORK TO BE PERFORMED, I <br /> HEW WELL BORING PT.GFOPRCBE.HYCROP NCH.HANO-A .i <br /> U'GER, OTHER') L7 DESTRUCTION�hoose r,- <br /> 'HCSCIL BORING: � s Eatc. ) <br /> WELL,. 0 OVERBORE <br /> )thee GROUT SFECIF;CATION 0 PRESSURE GROUT <br /> q <br /> OMMENTS: <br /> (PE OF WELL INSTALLATION TYP2 CONSTRUCTION$PECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF aOREHOLE .2j, MULTIPLE CASINGS? Q YES 0 NO WELL CASING OlA: <br /> VAPOR VTICM 0 AIR HAMMS—VORIVEN CASING TH!CKNESS rYPE OF CASfNG. CI STEEL - a PVC 8 OTHER: <br /> AFOR a MUD ROTARY DEPTH OF GROUT SEAL I1 TREMIE TYPE TC eE USED: Q AUGEP.S OHOSE y <br /> AIF SPARGE p PUSH PCOVT GROUT^EA.L BUMPED: C yes -Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30'1 l <br /> oOIL BORING' (]HANC AUGER(� GROUT SPECIE;CATION i a dSI I!! <br /> OTHER: CTr,LP.�O C fDb@+.4PPPDX.80R1NG DEPTH_ p`�.c�.�fY`P U SOOLTEC ��SAFF!C SOX or g STOVE PIPE <br /> 0CNOU.,TCR CrSadG pROPCS=D^ Il (if YES, lis:sp cificatl--s here)!! <br /> OMMENTS: <br /> QfL <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR OC <br /> NCRAENT ERMI St <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San J a In <br /> aunty Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. G�LrK <br /> i <br /> CA L THE Uij.�J�IV NNSSP/per\ TOR 48 WORKING HRS IN ADVANCE'FOR ALL REQUIRED INSPECTIONS . <br /> ;nedx --Y 11 _-i-. . -- ='1yy_ rtlfcompariy l�(72�iQQJY\ \ � $-• �il^ �ti^� <br /> t�L�� r.--- � �.... <br /> SITE MAP IN UNIT IV FILE ADDRESS !WORK PLAN DATED 1fil <br /> DEPARTMENT USE ONLY •1 <br /> )plication Accepted By Date Issued WE <br /> �L prey <br /> rot Inspection By i/ +nnn�w.- Date 2 - Final'Inspection H � Lltwenrm.., Data 2 O <br /> ?strucion Inspection By Date <br /> OMMENTS I CONDITIONS: c <br /> d�.r 1 5[/fin �i z3 R4 C <br /> 4CCOUNTING ONLY: AID' r•y <br /> Ie`CODES FEE INFO AMOUNT REMITTED CHECK T + P,EC'D BY DATE jt PERMIT/SERVICE REQUEST P I INVOICE <br /> GR# 0026L{0 q <br /> C-57_ WC/WAIVER_ C-57 Letter of Authorizationto sign per Il -Encroachment doc_ 7/17/CO <br />