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WELL PERMIT APPLICATION FORM <br /> f1R/f(i01ft4EN7 i.'HP,�AIOAQUIN COUNTY SITE <br /> �MW1R$ MVTAL HEALTH DEPARTMENT(EHD) MITIGATION <br /> E JeI,�T•Fiirct Floor, Stockton, CA., 95202 UNIT 1V <br /> 1 (209) 468-3449 <br /> NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joaquin <br /> Application is hereby made to San,Chap n County for a pennitto construct and/or install the work described. This applicatton is made to compliance wilh San <br /> VJCo�agQLujin County Development Title,Chapter 9.1115.3 and the Standards(�off San Joaquin County Environmental Health Department. <br /> Location Cro s Streal"K-k 1 N KCL C�,���ZP3 3�- Assessors <br /> //11V_�� <br /> Imo'---- Pdrrxl# pc <br /> PRERTY Ownef.. 'LI() n —r2 —�f9,,{��1L�77e�''"� ddreRQC57 Contracfo_'LLGSt&+SmuAddressu�� �' CIty41CDd(W� p�y�sr►6 LJcMp2. 'r e�j#, �g—Ztf.�.! <br /> salient sub Cntr^ LK C-otiY{1�}gy ddressZ�l r l� C1 �7tL <br /> —1) GIS Coordinates: CryUo#"t-`�^Phon�1�D—��3� <br /> I X �. Township �.�J Range &E Saclion�� <br /> J WORK TO BE Pr FO <br /> p NEWWo i aD ORING (C=T,GEO?ROB p^oi rNCH,HAND•AUGER,OTHER'S DESTRUCTION choose <br /> r WELLS OVER-BORE DIAMETER type below) <br /> i <br /> Other , RESSURE GROUT <br /> :. GOMMEs: Sn1.Q Iger S _ GRpUTSPEEO21CATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I& UX9SLCASJitr-G-CYtDT,t GnL.`iSDL1 JOW A96 <br /> I]MONITORING p HOLLOW STEM DIA,OF BOREHOLE tI0 MULTIPLE CASINGS „3 <br /> 0 EXTRACTION N AIR HAMMER/DRIVEN CASING THICKNESS 5 A MULTI-LEVEL WELL CASING OIA: <br /> 0 VAPOR MUD ROTARY Ur TYp�Oypf yCASING: 0 STEEL 0 PVC a OTHER; <br /> t 0 ' DEPTH OF GROUT S�'� WREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: �,kas 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 7 ' OIL BORING 0HAND AUGER GROUT SPECIFICATIONS <br /> L 0 OTHER: OTHER_15C28 i(_ APPROX.BORING DEPTH (,.jZ 9d f <br /> L <br /> ji 3 �y I 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> V1►Irb (� r d lAk1�ONDUCTOR CARING PROPOSED NA- (i, YES,list speeificadons to comment section) <br /> COMMENTS:_-(yl'�'La+ �w n,�.uAi( Lu 11 ilX�LnY�. jp�� ��J,�pn!- c�11 <br /> r NOTE. OFFSITE BORINGS REQUIRE ACCESS AGREEMENT ORR ENCROACHMENT HMENT PER I S. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 'hereby certify that I have prepared this app►Ication and that the Work will be done in accordance with San Joaquin <br /> county gg//rdl antes,Rt/�l�es and Regulations,and all applicable California State Laws. <br /> Signed x4w�'�/�,t/ry- ,c6Y.4-1 <br /> /�—/7--� Titla/ComrIDC <br /> pany <br /> r- is'Tint N6fis /1I/ <br /> l DEPARTMENT USE ONLY Data 1GGD? <br /> J <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> MORK PLAN DATEDI:� JGI/I_Z,GOLI 2 C(3 <br /> piplication Accepted By LM'ICM-Wl I b� <br /> �- Date Issued Ares 5 <br /> Trout Inspection By Date <br /> 7eslructen Inspection By Final Inspection By Date <br /> - Date <br /> OMMENTS/CONDITIONS: <br /> --------------- <br /> `COUNTING ONLY: AID# <br /> L.) FAC# <br /> 'ODES FEE INFO AMOUNT REMITTED CHECK# REO'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> l ! 7 SR* 'Y6G 3 <br /> WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Ehcroochment dot <br /> 9/30/02 <br /> 1 <br />