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SAN.JOAQUIN COUNTY <br /> ` ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton,CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3454 Fe (209)458-3433 Wieb:www.sigov.org/ehd UNIT IV <br /> >E <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appioa*m is hereby made to San Joaquin County for a panni(to constnrct andlor install the work described. This application is made in cmq iwm wkh San <br /> Joaquin County OwA klpnrerrt Tile, d loin 94115.3 and the ids of San Joel M Cmv ft Me9�DeparbrenN. <br /> ma Location 3S I oo tl �r� w a� ea Sty City 2�5 zip �53 85 WAY <br /> Owner g rA rl Address T D. 8o ZoYg city oek'ah zip952o Prunes 051L?-3K,;6 y <br /> c.7cm*oc ors r) A 1238 A/ice S (fir rpt-, S'-q s7 6 ucs Ph" S3©� <br /> CD <br /> coneumm strbcna h�lawt-SA1�Add e�Bro•v� Steil ggk,(�h� ups Phone 5 55 <br /> GIs CooMAullee:X Y Township Range section <br /> TO■IEPERFORMED: <br /> NEMi, (car,GEOPR13M HYDROPUNCH.HAND-AUGER OTHM) 0 DESTRUCTION(CHOOSE TYPE se-b" <br /> SOI.00RINM 11,2p GeDPR DRe SOIL Xk/&XS 0 � <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF(#MILL CONSTRUCTION 91CATIONS <br /> ❑MONITORING o HOLLOW STEM DIA.OF BOREHOLE -" // O MULTIPLE CAM=(3 MuLn LEVE. wee.CASH OK <br /> ❑EXTRACTION o AIR HAMMERK)RIVEN CASNNG THICKNESS NA TYPE OF CASING:o STEEL o Pvc o oTHER <br /> o VAPOR o MUD ROTARY DEPTH OF GROUT SEAL%f4/.-J-ek*-#wmm rim To BE USED o AUO Rtv,(mm-P VC <br /> 0 MR SPARGOOZONE o PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:o Yo No 010M:MA)(11SUr FREE-FAIL.DEPTH E X) <br /> D SOIL BORING o HAND AUGER GROUT SPECIFICATIONS %rilAnj, ce."e h f <br /> 0 OTHER: ❑armER: APPROX.BORING DEPTH 670 Ae e r o BOLTED TRAFFIC BOX OR o STOVE PIPE <br /> COrOUCTOR CASING PROPOSED (if Yom.at eoreorr In- Seco-) <br /> COMMENTS: <br /> NOTE: OFFWM BORNIMS REQLWtE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 4>! Foot <br /> 1 hereby 1 pnparad UraKt the Waltwait be dose IaceordarrF. web Sas Joogm6 County OrdNnrwe,Runts and <br /> 3 Wm 14A �T �o eLT- M a �/' [ f� aUtit- AX- <br /> PNnt Name ijgi- <br /> LtNYI I Osla ' <br /> USE ONLY <br /> SITE MAP IN UNIT IV FILE, S W J, , Q{S <br /> WORK PLAN DATED: / 4^' �Lo o y t <br /> APPLICATION ACCEPTED BY DATE MoSUIED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> ACCOUNTING ONLY: AIDS FAC E <br /> PE CODES FEE INFO AINT RErTTCHEM* e RECIPD BY DATE f SWUM <br /> 0� 99- 3�- 107-,-5 -70 1L1jP11'& s <br /> C-57 VMC C57 LETTER OF AUTHORIZATION TO SIGN DOC <br /> EID 2MI 10R8M WELL PERMIT APP <br />