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SAN JOAQUIN COUNTY <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-029 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EMIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a pennil to construd andfor install the work described. This app6catbn is made In coffiIAWoe wt1h Sen <br /> Joaquin Canty Dareiopmerrt Tillie,chapter 9-1115.3 and the Standards of San Joaquin County BwkmrTw"Flealin Departnternt. <br /> M.N L..o,.35 27 S W 61�Y Steal /' a 33 Asseaaors <br /> , <br /> city r i ZIp g5�85 Parcels 2 SS-O&-Gid <br /> N o r W a vt N U kjf-e-r Address a o i Ve ally I Ce f i c(j apq 45 0`( R,,,s 1 5 6- <br /> c-7 carrwmftr ►wdreas146�p Ave City i zo3y9bgLks 28 32.E �53 <br /> con>..ftftk*cna Banka;A4 SAKnva /Ooo 13roj"yie(_v?-1&y, klah Li.* t�horne 559 38-7(, z <br /> GIS CoordinaMa:X Y TownsNp Range Section <br /> WORK TO W PERFORMED- <br /> 0 MW WULLAKIRM(CPT,GEoPRoeE.HrDRoPL*cH,wwD-AucER.o7mw) ) ovER-eORE NTYPEdAI TER 5 BRJYM <br /> 0 SOL NOW"❑WELL s C]PRESSURE GROUT <br /> a*OTHER GROUT SPECIFICATIONS <br /> 0 ExPLOSP�ES DETONATING CARP <br /> COMMENTS: Mw— I , A4 w- L 3 <br /> MMLQEMLL TYPE <br /> MONITMNG t&LL0VW STEM DIA.OF WR840LE L15 ❑MULTIPLE CAsl M o twin-Leve WELL CASING M:Z <br /> ❑EXTRACTION ❑AIR HAKIMER NUVEN CASING TE ICI NESS TYPE OF CASaNa❑STEEL NtVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL Ir TR9AiE TYPE TO BE USEDNAUGERS❑HOSE <br /> ❑AIR SPAROEIOZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PIPED ❑Yes0 No (MOTE:MA)MIMIJM FREE-FALL DEPTH IS 31V)0 SDu.BORING [IHAND AUGER GROUT SPECIFICATIONS IO C I fA h d C e ✓L I If h <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH YD"7 5 D BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASOOG PROPOSED a YU.W sp.dfarmm in comwm t secYon) <br /> COMMENTS: <br /> NOTE: OFFSITE BORNM REQU11RE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> '"WWWWWWOURMIRS 506071m <br /> 1 im s"cod*pwjwm pmpnv Imp Led OW the wroo will bo done i aeeu>Ardan r with San Joeq in Cooky Ordlrmneas,Rulaa and <br /> Signed Tmac—qmny (o e�f I�ah� e� c - SAl C <br /> Prirrt Nave W i I l i a we Slow;k Date, O <br /> WE CALY <br /> SITE MAP IN UNIT N FILE,ADDRES§ <br /> WORK PIAN DATED: <br /> APPLICATION ACCEPTED BY _ DATE ISSUE D AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> ACCOUNTING ONLY: AID d FAC S <br /> PE CODES FEE IWO AMT RE TTED CHECK i e RECV-D BY DATE P£J0111/JERVICE S IMVOICE <br /> a- aZ_ 0- 60 o 74Z Srt#,/,v <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN'PEFWT ENCROACHMENT DOC <br /> EHD 2"1 10rAW WELL PERMIT APP <br />