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ff co <br /> San Joaquin County P Y <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rdFloor, Stockton, CA 95202 MITIGATION <br /> ` (209)468-3449Fax:(209)468-3433Web: vww.Sjgov.org/ehd UNIT IV <br /> a Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to const.a-1 an(Vnr Install the wrnh descrb»d. This application is mado In compliance wan San <br /> Joaquin County Develommant Tiite,Chapter9-1115-3 and tFa Snndards el >,:n,iCe,ngokt County Env,orm_nlal Health Dypartnhent. 145o3 00to <br /> WELL Location 1c) 1 Cress Street 4U'. Ass-ssors 1V503oo'/ <br /> .f � 9.1 '."�a —._ *"Gt C'iYSt6C lt.�- .....Z'p_`1. 423 ParG4!#. 5 <br /> PROPERTY <br /> }aner _ WGwcbm. <br /> Address.re40 <br /> sr pE i,��g,,oe Aac zi .±rk_7 <br /> �P�aneNT <br /> [o _ Cdy fl / Pi,46�,k75 <br /> PGonsuita t15vtr Cntr- _ AU Addre<Si55� _�tteCGty );pad LkYt Pone#roLO- 1. (� <br /> GIs Coordinates:X ,Y ,Township Rarnte. Section <br /> WORK To BE PERFORMED: <br /> ANEW WELL I BORING (CPT GEOPROBE.HYDROPUNCH, AN0.AUGER: THER') 'DESTRUCTION (choose type below) <br /> ��{{SOIL BORING# n V OVER-BORE. DIAMETER <br /> r0'WELL 9 PRic&URE GROUT <br /> O'Other - L � GROUT SPECIFICATIONS <br /> COMMENTS: g/LRn GtGCUiLd A4t. -e'e-C4 &&"Z.e /5)AAA c � s., <br /> TYPE OF WELL INSTALLATION TYPE g,C3N+ R CYtON.SPEGI✓FIGATID„N�. " <br /> D MONITORING D HDLLOW STEM DW OF BOREHOLE 4 th 0 MULTIPLE CASINGS 1]MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION DAIR NAMMERiDRIVEN CASING THICKN=SS_—TYPE OF CASING: D STEEL O PVC D OTHER: <br /> n VAPOR O hAUD ROTARY OFPTM{OF(;ROUT S=Ai_ TREIVIE TYPE TO eF USCD: B,%uGERS U HOSE <br /> D AIR SPARGEI OZONE O PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes )KNc (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1<kSOIL BORING DIY ANOAUGER GROUT SPECIFICATIONS <br /> II O OTHER_ ^nn OTHER APPROX.BORING DEPTH �'�. .}} D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> //-j �(f/� n CONDUCTOR CASING PROPOSE (if YES,list specifications in comment section) / <br /> COMMENTS: /d7/6 S 44i p�J p j/ &jkA4-V4 or <br /> , <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 Ordinances,Rules jand Regulations,and all a pli ble California State Laws. <br /> 2�> _-�� I A Troe t m p hy_ ,ne-� +tzt� <br /> Sill _ C olts <br /> ad�t uomo__ v, <br /> DEPARTMENT USE ONLY 1 ;' "'-"r ( -7 ;q <br /> SITE MAP IN UNIT IV FILE, AD RESS: � Z +' 60 <br /> WORK PLAN DATED: Z yoo6 [�(_L/ <br /> Application Axepled By _ Date Issued �Z$_0 t0 Area ©!a <br /> nrmh Inspection By_ Gate`__ -__..-_frnai Inspection By Oale <br /> Ooalraction inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# ,_..._ FAC# i <br /> PE CODES FEE INFO AMOUNT REMITTED CRECK# REC'D BY DATE PERMIT(SERVICE REQU_ST 4 INVOICE <br /> ;2 of sB I 8q 510 ? sr _Z2 _ <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign perinft�Encrrrent doc ✓ 'f" <br /> END 29 02-001 � <br /> �?IM <br />