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<br /> Ld.�IsvrN„< SAN.JOAQUIN COUNTY
<br /> �,.,', .. ` :•.7,i ENVIRONMENTAL HEALTH DEPARTMENT SITE
<br /> 600 East Main Street, Stackton, CA 95202.3029 ITIGATION
<br /> Telephone.(209)46$-3449 Fax:(209)465.3433 Web:wtrwv.siaom--orate NIT IV
<br /> WELL PERMIT APPLICATION
<br /> NUN-REFUNDABLE PERMIT EXPIRES t YEAR FRbM^DAT:E••158U�t3.'�
<br /> Appllohnon Is hereby made to San Joaquin County for a permit to conatruet end/or inVall the work desoftgcl. Thj. gpptlC0li0t� rP��ta� {�n� nCe with San
<br /> Joaquin County Onvoropmanl T41te�Ch t r C 11��S nd the Standards of San JoagOn County EmrironmeMIDI U' 1W tlefiitidt` nil� $
<br /> Wait Location �fc '(v ""_ cross Street 3=v� �or�p Ph yr oily ingG ; Parcel Ir 7�402Q 33.
<br /> Property - .. Pe7lk�t
<br /> owner Wi r' ;� Ct e .{^1Y Addre6e ru_cr�,fY�7gt+u . �, L?.� Crty.V ,.. i zip PhoneN '�a�_'61 D
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<br /> CaT contractor � p � 1_ 7IP Llc9 � Phone
<br /> `58oC
<br /> ConRulta SvbCntr.,°N''��' ' �`!r!r-8 Add,e64.,Sq� �i,f,� i � city 5m& LiCc. �/,� Phones/D-Y20 �37t l
<br /> �Fssot, _ --
<br /> GIS Coordinates:Y,-. Y ..___�.,,....Township _., ..,. _.... ,.. Range Section
<br /> WORK TO BE PF�$ $�1ER: I
<br /> PE-NE WEt RIN CPT, ;vOPR09 bIY tzOWUNCI•I,}+ANO•�+VGtsIi,OTMQR'I I]DESTRUCTION iCHO05E TYPE BELOW}
<br /> bet SOIL BU��Int'G1(�},. 5. ��....,__._..�„ ❑OVER-BORE DIAMETCA _
<br /> WELL N ___..._. --....--...._..... _.�_.__.- ❑PRESSURE GROUT
<br /> •OTHER _ „ ..► f. -, GROUT SPECIFICATIONS_-
<br /> COMMENTSSli .••-_ C- ., ..�acr '_�!%t1e.�CJ' .��=-*� (?d.'_.Ilr�t__ ..33 � mP�-- --_
<br /> IIII�YIYw11Yl ■IIIpIIiIrYInY I III.I
<br /> TYPE PF,.Vffi6 INSTAtLA"3YP-E a"§TRUjD9N SPEC#FICATIQNS
<br /> I�MON17OR;NG II HOLLOW STEM DIA,OF BOREHOLE .Y ;O C)MVLTIPLF CASINGS Q MULTr•I,EVEL 1NE1.L CASING OIA:„.^
<br /> ❑EXTRACTION Q Atk HAMMERIORIVF-N CASINC TwckNG85 .l,1[ TYPE OF CASING;0 STEEL ©PVC 0 OTHER
<br /> 1]VAPORTO UE USED__.., �( `t:Q •TYPE: ©AUGERS t3 HOSE j
<br /> ❑PtLrO I�lO'I'ARY.,..-,_„.,. OEPTIy OF C0.pUT SEAL-!6TREMIF,.
<br /> C3 AIR SPARGEfOZONG PUSH pt)rrrt flrP OR C'T}�, • CROLIT SE%,pVMPED'p Yes IXNG (NOTE:MAXIMUM FREE-FALL OEP'TH 13 30')
<br /> *D5�;QIL GORING C)KANO AUGEh2_.. ,�Oltt7tJT SPEGirICA1'lONS �f 71!!k vdi �., F��� D P+rLI {CdfL- "'ark
<br /> ❑OTHER: _N []OTHER':•__,�...,- _., APPROX.60RfNC3 01:a•r4 U ©_ BOLTED TRAFFIC 6QTOVE 4X OR $ PIPE1/
<br /> ^T'""'• ' Ctavt)uC70n C4�IraU aaoPD9�"'_,� "'.. I'YaO.hni ru.eln�eetiana Mtvrrl�!nl x+cs�aM1l
<br /> COMMENTS'_„•,..._.__. .: ...� ........ ;
<br /> NOTE: OFFSITE SORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS
<br /> 4B WORKING HOURS NOTICE REQUIRED FOR IT45PECTIO145
<br /> I hereby eentl'y that 1 have Pr re is a Icap,91d that the Work will ee done I accordance with San Joaquin County Ordinanae6,Rules and
<br /> Requtation6,an I P i u Law
<br /> TiitelComvenY VtE it _ 1L,. J � Y
<br /> Signed _.,, . _... . _ ... ._.....___.__............ ...._ � �i� ��
<br /> Print Name Data 2-�
<br /> DEPARTMENT UM ON
<br /> SITE MAI'1N UNIT IV FILE.ADDRESS: ._..Z .- - � ..t `�` ` -
<br /> a ------ _— .r ��/
<br /> WORK PLANt)ATED:�_._ -.4
<br /> APPI•ICATION ACCEPTED BY [•� __... ---.--. _•- ^__ DATE. ISSUED ==T � ^AREA _
<br /> GROUT INSPECTION BY _. .u+._._......._,....- -..._.._—..... ...,_ FINAL INSPECTION BY „� •,_ DATE
<br /> DESrRVCT10N INSPECT€ON BY --- .. OATS_...,.... .�._ ..-..-. ....- 6 = -
<br /> COMMENT5ICONOrrIONS:
<br /> ACCOUNTING ONLY: _ f Alp R _ FAC n _
<br /> til;CODES FEL INFO AMT REMITTED CHECK IN REOV'D BY DATE PE.RMITISERVICE a INVOICE
<br /> 35'oI �q"oc
<br /> 1.e3?--5 UQ- SR# !'`151`Ifo
<br /> C-57 WC ^-WAIVER C57 LETTER DF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DRC_
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<br /> eHv:�oi i!r5ro� WE�LPEFjNiltAPP
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