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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE 600 East Main Street, Stockton, CA 95202-3029 MITIGATION Telephone:(209)468-3449 Fax:(209)468-3433 Web:vinrw.siaov.Drg/ehd UNIT IV WELL PERMIT APIPLICATIM NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM TE 1$SUED Application is hereby made to San Joaquin County for a permit to construct andfor install the work described. This application is made in compliance with San Joaquin County Qav�ptr T chapter 9.1115.3 and the Standards of San Joaquin County Environnienial Health Oepartawnt - .Z I&J IV• *,�,d Assessor's Weil Location Me-DomALD iSLAAIU Cross oueet M- 7ijneF9HAM RD City UNI hY'W, Zip Parcel# 1290,9609 Property Owner t�AeE CaAS ELEtTi1tIG Address 3jQlC90W!r=8NYn1J RD City.SAN 9AHON ZIP-21583.Rhone#12S--f15-081 oc" 1'7G C-57 Contractor PZS' D R)L 1>�w Address City W 00 GLAND Lic#802334 Phone 630-4d4 A-2.4 29 Consultant/Sub Cntr tISE 6112Gt1P Address 3OZ PEJUDLP-TDN 20 City OAI,LAjtJ0 Lic# Phone 5i!}-3e-7-96f�C GIS Coordinates:X—!a..'1 900 Y 3A-0013 Township Z(J Range 4E Section 2— WORT(TO HE PERFORMED: ❑NEW WELLMOR1NG:(CPT,GEOPROBF-HYDROPUNCH,RANO-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPE BELOW) Q SOIL BORING# OVER-BORE DIAMETER ❑WELL# PRESSURE GROUT ❑'OTHER GROUT SPECIFICATIONS 9-SA�1C y%&X - COMMENTS: F101VrIV9ikC WE)l!Jyw-ts?A)- -2 -3 ' }�'S 'G -7 0.-Q� !Q, -tl� ;QHerr-R5 f�iA.-Id -2-A_�--ALAe-AA.-3A . -9A. -qA. -7: r +iKa!<'lIQY Pir-7n` ETERS "rP�t-J. Y TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS T, ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA. -1 E:<TaAC(ICN ❑AIR HAMMER/DRIVEN CASING THICKNESS - _ "''PE OF CASING.❑STEEL ❑PVC ❑ OTHER ❑ /APOF ❑MUD ROTARY DEPTH OF•3ROUT SE-4,L TREMIE TYPE TO BE USED❑AUGERS Q HOSE ❑?.IR 3PARGEiCZONE ❑PUSH POINT(GP CR CPT) _ GROUT SEAL PUMPED:❑Yes ❑Nc (NOTE:MAXIMUM FREE-FALL DEPTH 1S 30') ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATICNS ❑OTHER: _ _ ❑OTHER: APPROX.BORING DEPTH _ _ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR r-%SING PROPOSED (if YES.11"specilleatlas in cmwneN sealer) COMMENTS: NOTE: OFFSCTE 13dI;t11 S REQUIRE ACCESS AGREEMENT OI ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE RECOIRED FOR ININFECTIONS w I hereby certify that.I have prepared this applleation and that the work will be done I accordance»ilth San Joaquin County Ordinances,Rules and Regulations,and ail applicable.CalNennia taws. Signed TitielCompany PIZ06RAN HANACER,, ME GROUP � Print Name Pf3A Ff21 A F=L AS Date 7/291jQ9 ` DEPARTMENT USE ONLY n 1 �] r SITE MAP IN UNIT IV FILE,ADDRESS: �� C.Ia �^ a-- b L )1), � 7�a 11 i. WORK PLAN DATED: w24 p` APPLICATION ACCEPTED BY TE ISSUED -30 AREA997 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION:BY DATE d COMMENTSfCONDITIONS: al Pi,MP sin �b�nLla.ttu r.I[ elys.AA dngA�!nj/- ,enn�,e r ACCOUNTING ONLY: i AID N FAC# _ PE CODES FEE INFO I AMT REMITTED CHECK# RECV'D BY DATE PFRMtT)sERVICE 1t INVOICE og by I 60- �laa► ,ctG ?/sv e� SR9060011-4 C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC 1115a71weB) WELL PERLOr APR