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SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 96202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(249)468-3433:Web.www.sigov_ar-wehd UNIT IY <br /> WELL PERNTAPPLICATION <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 comptlance with San <br /> Joaquin C De 'Title chapt3er 9.1115-3� 1.the Stands of S��peQyx�County Environmental Health.Department <br /> °2`�', ������r�tki�t q� )0 'f're �'�` -6i. � Assessors <br /> Wall Ln®tim k Doltul:D LSL.ANO Oras Street M: �.vrrEiMAM RD City ttnll KY,E'ttt P tip. Parcel# iZ9�3i�d9 <br /> Propariy Phon&A-925-415-0 <br /> 6wner PACIFIC GASB E 1;EeTkIL Address t t! N _ C ty.SA1e1'Ni At>`tOrC1' Zip �t�. j <br /> 2001'1't7 <br /> C•57 Contractor 99L Dl3jL-Lj-*kjAv Address CityLie#80233'1 Phone 530-G.6"a-2424 <br /> ConsuitantlSub Crrtr 115E CwjWVj0 Address 3Q2-t-fAjj2jETON R-L City OAA ANQ Lic# phone 51d,�-38:9-9Lff�J <br /> GiS Coordinates:X—111.'190 Y :38„r00I3 ,Township 214 Range 4E7 Section 2-1_ <br /> WORE[TO BE REMIGRMED: <br /> I NEW WELL(BORING lCPT.GECPRCBE,`?YDROPUNCH,HAND-AUGER,OTHER-) 1$DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL* 56 PRESSURE GROUT 4+ <br /> ❑'OTHER �t GROUT SPECIFICATIONS 9--5APIL-AF:HI14 X OF <br /> �CMMENTS: HQN17t7gl" iA]FLL hl�1t-OZO -Z.-3�y��'4 -+�p Y-9--�0,� ; i 0 _1 - <br /> -4A -sa -77 i�Moog-A r i�lE7cMETERs rug--:jw_z =t -S. e�.e.i am Z_ <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Ll MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING.THICKNESS TYPE OF CASING:❑STEEL ❑PVC (3 OTHER <br /> f� <br /> ❑VAPOR I]MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGEiOZONE 0 PUSH POINT(GP OR CPT)_GROUTSEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER' Q OTHER: _ APPROX.BORING DEPTH [3 BOLTED TRAFFIC BOX OR I]STOVE PIPE <br /> ---- - CONDUCTOR-CASINGPROP09ED (If YM list S11000M11IMMl a mrrrmseatanl <br /> COMMENTS: <br /> NOTE: OFFSITE BOROW-S REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 2 <br /> AS WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby earthy that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordimacas,Rut"and <br /> Regulations,and all applicable CaNfornia Laws. <br /> Signed _ TitleJCompany PR06RAH HANACEIZ NSE GROUP <br /> ?nnt Name �t �E Q"r d L._ AS Date <br /> �DEPLARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �� N' 2 �Cg�SA". . A j, <br /> WORK PLAN DATED; �'�' P 2�4 � �•r ' <br /> APPUCATiON ACCEP BY- t DATE ISSUED 3O O AREA 97 <br /> GROUT INSPECTION BY FINAL INSPf-C719W BY DATE <br /> DESTRUCTION INSPECTION BY 1J f AGOC.C. DATE j ,� ! <br /> COMYEII OITtC1Nt3: alil 44.d OU t� to�'� -6- I t�ikL <br /> k,•#wv- A s" <br /> ACCOUNTING ONLY: AM# FAC# <br /> PE cacES FEE INFO .t111111TRmTrw cmECK# RECY'D BY DATE PERMITlSER ME# INVOICE <br /> a-5a� 60' bo 9881 I 73o Le I swev- , <br /> C-57 WC -WAIVER C57'LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENTDOC <br /> EHO 2941 11PSN IWES) WELL P-I;4rrA <br />