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t It/2912003 14:56 2094L .433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLI ATION FORM <br /> SAN JO, C LINTY SITE <br /> ENVIRONMENTAL ,HEALTH D PARi'MENT(EHp) MITIGATION. <br /> 364 E. Weber, Third Floor, St ckton, CA., 95202 UNIT IV <br /> RO <br /> (209) 46834 9 <br /> APPlIC2tion IS h0te6oaquin NO -RE PI) SL E IT XPI S 4 IC <br /> Joaquin CountyDevelopmantTitle.IChapter X1115�nd theiS a� SonJSU Eq <br /> t 00116 instal!the work viron[}ed.Ighs aPpficapon is mad8 fn eompgano with SsR <br /> of SanJoaquin untyJ:nvlronrnentalHealth Departrnent,WELL I-oG2tEon � l✓ �S Slre6t •�, Assessors <br /> PROPEM Owner �p�,ParceJ# � � �/_13-/ <br /> Address o n <br /> "7 ContractOr� / <br /> r--�Q,ct r..1r Addresses �7rp`�& idR o <br /> Canstiltant(Sub Cntr ,gJ ¢+ plc <br /> Addr CilyC��vR <br /> GIS Coordinates;X <br /> Y .."Township <br /> Se <br /> (T EP RF M ; <br /> ` NEW WELL/130RII�IG (c G::oPRo6 .t�yDROPI)NCH,HAND-AUGER.o HER•) Q DESTRUCTION choose OIL BORING�! type below) <br /> ELL <br /> 11 OVER 80FtE D1AMElER�' <br /> other 11 PRESSURE GROUT <br /> COMMEtVTs: GROUT SPECIFICAT110N <br /> TYp@ t?F tivELl IN-41ALULATF0Njype ONSucjn <br /> �MONFFORING SI' GIFIC TIO <br /> HOLLOW STEM DIA.OF BORR�-IOLp �` <br /> Q EXTRACTION Q MU TIPLE CASINGS 11 MULTI-LEVEL WELL CASING DIA: <br /> Il AIR DIA <br /> CA$iNG THfCKNI=SS I70 TypE OF CASING: [1STEEL C <br /> 17 VAPOR Q MUD ROTARY DEPTH OF GROUT SE - _r Q OTHER: �-- <br /> r'" JR SPARCSE/OZONE USH POINT GP or C EMIE TYPE TO BE USED! )kAUGERS 11 HOSE I <br /> CC GRbUTSEALPLIrytpEO; e3 No NOTE: MAXIMUM FREE-FALL IS 30') <br /> 3 OTHER! <br /> BORING Q HAND AUGER GROUT SPECIFICATIONS ' <br /> 1]DTFIER:_ OTHER--- `4 APPROX BORING DEPT <br /> BOLTED TRAFFIC BOX ar Q STOVE PIPs i <br /> CONDUCTOR CASING PROPOS D J <br /> COMMENTS: z��(f YES,list specffcations In comment section) <br /> NOT OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE kI=QUIR D ..............AOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and thatthe wor will be done In accordance with San Joaquin <br /> County Ordinances, Rule and Reaulations,and all applicable Callf0i7lia State Laws. <br /> Signed x <br /> TH101Comp2n S <br /> Print Narne <br /> DEPARTM NT USE NLY a8te - -c <br /> SITE MAP IN IT IV FILE,ADDRESS: <br /> NORK PLAN DATED: <br /> Wilcation Accepted ey <br /> grout Inspenrr By. <br /> ate Date I sued O Area�� <br /> tFi " <br /> nal Inspe on Icy <br /> ?S90iction inspec on ilyetiadte Darr <br /> ;0MMENTS/CONDITIONS. <br /> ACCOUNTING ONLY: A.1D# <br /> FAC# . <br /> APEc(0)Dm FEE INFO AIUIOLIh17'Rl=1V11TTEd CHECFf# <br /> RECD BY DA PERMIT/SERVICE REQUEST* I1VypICE <br /> 357 <br /> ID SRi# 00 <br /> WC - - WAIVER C-57 Letter of Authorization to sign permit Encraechment doe <br /> . 9/30J02 <br />