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r <br /> f <br /> o n�ln SAN JOAQUIN COUNTY <br /> ? ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> "'• 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> �.. Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.siaov.ora/ehd UNIT IV <br /> l l'•o..Ni <br /> 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 construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Develcpment Title,chapter 31115.3 and the Standards of San Joaquin County Environmental Health Department. Assessor's <br /> Well Location,l3PaMWL-4D AVLIN1� Cross Street WrrJS71� R4Gib %A 4'Y City L4P40WP Zip $53'50 Parcel# 14L•o67 ZZ?Z3 <br /> Propsrty � O Phone#Zoad-391�TZd'O <br /> OwneNTY OF LA•nkro� Address '&R 1NAINE CD.ultK DaJ�� city {,µrlilL7P zip gS33 <br /> c-sT comrocror wDL Jtuu+Ny�wLs1S Address ?/L$CIX I9( city 7AwIZA Lic#•9336 Phone 53n—66t•LGZ9 <br /> onsulta ubCntr 0" Address Z(5'70 OAKS Olt City96z4WlT1Lic# Phoneltfi 6Zei'z259 <br /> GIS Coordinates:X Zt71634 'el ,Y 6337SHj•NB ,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(CHOOSE TYPE BELOW) <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER-) ❑❑OVER-BORE DIAMETER <br /> ❑SOIL BORING# E]PRESSURE GROUT <br /> ®WELL# s..1nz3R - <br /> ❑-OTHER GROUT SPECIFICATIONS <br /> COMMENTS: SG1EI xQ INTQZk/4'1,• if6 — 13L FBGT' 811.5 <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t` <br /> TYPE OF WELL l <br /> [I MONITORING El HOLLOW STEM <br /> OLA.OF BOREHOLE Iby� ❑MULTIPLE CASINGS�MULTI-LEVEL WELL CASING OLA: rJ• <br /> AEXTRACTION ❑AIR HAMMERIDRIVEN CASINGTHICKNESS �-'-L o TYPE OF CASING:❑STEEL [HPVC ❑ OTHER <br /> ¢ DEPTH OF GROUT SEAL L—TREMIE TYPE TO BE USED AUGERS 0 HOSE <br /> El VAPOR P'MUD ROTARY <br /> 0 PUSH POINT(GP OR CPT)__GROUT SEAL PUMPED:P1Yes E3 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑AIR SPARGE/OZONE <br /> GROUT SPECIFICATIONS NFYf1 gM •/ . �IrnND•gr , 74iAf-I C1�'14LQS f G <br /> 0 SOIL BORING ❑HAND AUGER Q <br /> APPROX.BORING DEPTH (��' LS tsOLTED TRAFFIC BOX OR []STOVEPIPE <br /> ❑OTHER: ❑OTHER: CDNDUDTOR RING DEPTH <br /> ED (if YES.list apeb6 tM in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby c <br /> he a ared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulatlo ,7d d n a Jica Ca}(f�roia Laws. G am'/ST <br /> 1 � Title/Company <br /> Signed Date <br /> S/z>l aq <br /> Print Name 'rZ� ILt.(PS <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PIAN DATED: C M1'`w` 11 Q O ii DATE ISSUED AREA <br /> APPLICATION ACCEPTED BY DATE <br /> FINAL INSPECTION 8Y <br /> GROUT INSPECTION B 14 DATE <br /> DESTRUCTION INSPECTION BY f( D'C'G •• S�,/�re F��: a-`7.b O <br /> COMMENTSICONDITI ONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# CHECK# <br /> RECV'D BY DATE PERMI7ISERVICE# INVOICE <br /> PE CODES FEE INFO AMT REMITTED <br /> ^t'a - ENCWROACHMENT DOC <br /> 6r-7 wELLPERMITAPP <br /> WC •WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PE iT <br /> C-57 <br /> EHD 2MI 111SNT W"), <br />