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SAN.1OAQUIN COUNTY 0 ECENED <br /> ` `' ENVIRONMENTAL HEALTH DEPARTMENT <br /> CA 95202-3o2s JUIV 1 6 [U i0 SITE <br /> 600 East Main Street,Stockton, MITIGATION <br /> Tereprwne:(209)4W3454 Fax:(209)468-U33 wen:www. i NT HEALAbNIT IV <br /> WELL PERMIT APPLICATION PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby nude to San Joaquin County for a permit to con*uct and/or ireal0 the work desaibed. This appNoelimu is meds in ooffOw a with San <br /> Joaquin Coady Dewrloprnent Tlbe,dIsift 9.1115.3 and the of San Joaquin County ErMrorrnerMal H830 DePwbnw t- <br /> wwI Lommon 3527.5 W c!fy btoessintet Wq4wav 33 C,y \/e'v a l i s zip Sm S P 2 5-0/S-00 <br /> Pn+a«ly wle nf2 31 a vI niye h 'e D wane# �2 - <br /> �aAddress CRY ziP`1 �15 <br /> c-7 contrsdw i j n Z 38 q�iC.e E 5�p.� city zp �t.ic# /- <br /> Coasu ubCnt,&inbam-SA�l00OB(oaju�av�Sfe.G1�y()AK LAND Uc# wane 554 - 55- <br /> GIs Coordinalss:X ,Y ,Towns* Range Section <br /> TO tiE Pte: <br /> (CPT.GEOPfWW HY FA on*w) DESTRUCTIN(CHOOSE TYPEBELOW) <br /> Two Ge PROBE 13aA/N6 S OVER <br /> vbm BOW DIAMETER_ <br /> L 111 p PRESSURE <br /> GROUT <br /> 0*OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING GARP <br /> 00MMENTS: <br /> TYPE OF VABJ4 <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3-`I' El MULTIPLE CASINGS(]MULTI-LEVEL WELL CASING DIA: <br /> O EXTRACTION ❑AIR HAVAIERIDRIVEN CASINGTHICKNESS tJ 0, _TYPE OF CASINQ 0 STEEL❑PVC 0 OTTER <br /> Q VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL -0 L ZICAWNE TYPE TO BE USED O AUGERSXtMe PVC <br /> 0 AIR SPARGER)ZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:0 Yes No,{@ME,MAXIMM FREE-FALL DEPTH 18 3W)0 SOIL BORING D HIND AUGER GROUT SPECIFICATIONS D r!�1'� CP hN P dl <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH _A50 T e a-L 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASWG PROPOSED a YEa see�psdlbsroew h aomma+t seesan) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQWRE ACCESS AGREEMENT OR ENCROACHIAENT PERMITS <br /> FOR IMECUM <br /> benhy oselMy I hwa amd that the wo wilt be aow•.I-r p n -asee with Baa Joagon County Ordinances,fades and <br /> Laws. <br /> stented ,itielroerlparey r "e f- Nie v►a tr- I�eh�iar�r SAI C <br /> Print tortes W i l l fol o u S IDLJ)k Dale ILI) <br /> Um Y <br /> SITE MAP IN UNIT IV FILE. y, J W <br /> WORK WAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA 9 q 2 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION 04SMCTkNI BY DATE <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE SAO AMT REMIT® t mm"a('j REC"BY DATE P19111110117SERV=0 G57 WC -VWUVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EtD 29.01 101 109 WELL PEW APP <br />