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WELL PERMIT APPLICATION FORM- <br /> RE <br /> SITE <br /> CO " ED ENV SAN JOAQUIN COUNTY S MITIGATION <br /> IRONMENTAL HEALTH DEPARTMENT (EHD) TION <br /> FSB 2 4 2404 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 <br /> twmi&LTH NON- EFUNDABLE PERMIT EXPIRY 7 YEAR 1~R M DATE ISSUED <br /> Ae,an Joaquin County for a peril to construct and/or install the work described. This application is made In compliance wHh San <br /> Chapter 9-1115.3 and the Standard1,,,n eJa in Coon Envir Environmental o mental Health�Dy,e�p-artment. <br /> WELL Location j, 1)44 Cross Street �, �[`G zip 4�3�� Parcel#.i� -11U�Assessors 3 <br /> PROPERTY YI T thvl LAsucy, _ ^� <br /> Owner 4c�u far ,tSk_Addressi- <br /> C-sr contractor rt Address 4mc_-�.sL.�`�Clty * Lic#R S horie#�j�9 <br /> Consudant/Sub Cntr Address City—Lic# X�Phon <br /> eQ_Wtly,�.?� <br /> GIS Coordinates:X 'Y Township Range Sectim <br /> tIiIO RFO <br /> EW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") Q DESTRUCTION (choose type below) <br /> L BORING#;WRQ OVER-BORE. DIAMETER <br /> L* Q PRESSURE GROUT .. <br /> •fir <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE Qf WELL INSTALLATION IYPE CONSTRUC71ON SPECIFICATIONS <br /> Q MONITORING OLLOW STEM DIA.OF BOREHOLE, Q MULTIPLE CASINGS i}MULTI-LEVEL WELL CASING DIA:,4 <br /> 3 <br /> 0 EX'T'RACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSej6 4b-_TYPE OF CASING: O STEEL WOVC 0 OTHER: <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL_—a* TREMIE TYPE TO BE USED: AUGERS Q HOSE <br /> Q AIR SPARGE)OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 13 Yes avo (NOE: MAXIM M FREE-FALL DEPTH IS 30') <br /> Q SOIL!BORING II HAND AUGER GROUT SPECIFICATIONS �T� <br /> II OTHER: 11 OTHER APPROX.BORING DEPTH_____aS��WOLTED TRAFFIC BOX or ©STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED— AIV (if YES,list specifications in comment'section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordl ces, Ru7i .and-Regulations,and all applicable California State Laws. <br /> Signed x pp Tdwcompany <br /> Print Name Q7�-1 GWS _ I LI/t'l&I <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Apoicad0f i AOepted By_ Date Issued Area <br /> Grout Inspection By Final Inspection By D <br /> ate <br /> Destruction Inspection By Date . <br /> COMMErfrS 1 COITION$: <br /> ACCOUNTING ONLY: AJDili <br /> FAC* <br /> PE CODES FEE IWO AMOUNT REMITTED CHECK* REC'D BY,I DAYE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3 .5- !?vo SR# 3 <br /> C5 WC_-WAIVER' C-57 Letter of At It' arizati t sign rmit Encroachment doc— 9/30/02 <br />