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1'9129!2603 14:56 2094L1.--433 FIFTH FLOOR PAGE 03 <br /> WELL PERMIT APPLI ATION FORM SITE <br /> SAN JOAQtlIN C LINTY <br /> ENVIRONMEMTAL HEALTH D PARTMENT(EHD) MITIGATION <br /> 304 E. Weber, Third Floor, St ckton, CA-, 95202 UNIT IV <br /> (209)468-34k 19 <br /> lLO -REF DAI3 P>= T ES 7 OM T1=15SUEt? <br /> Application is her�>�y rrtade to San Joaquin County fora'permit to consfruet and/or install a Work described. This application Is made in wmpiiance wEth San <br /> Joaquin County Develapment Tile,Chapter 9-1415.3 and the S dards of San Joaquin unty Envrronmenta!Health Departmenk <br /> !VELI,Location L'� / � _ s Sipr� Assessors <br /> ity �p _Parael# •1 _ DC7( <br /> PRoP✓~R7YOwr,erSf1_C��?ir�c �Adaress 1a ,oa cr�crR <br /> C-57 Contractor 5y � Isl4 ,�Phon n <br /> Consultant/Sub Cntr�'�7fT ./✓� +r �m S`� <br /> �Adtlress � �ioc. �6e �� <br /> Phane#�L6 <br /> GIS Coordinates:X Y Township <br /> Range Secuon <br /> KEW <br /> Q B RF MED•WEI.I t BORING CPT EOPROB YDROPUIVCH,tigl+tp AUGE1 ,a ER-) 8 nEsrliucrioly (choose type below) <br /> OIL BORING# <br /> ,'WELL# d OVER-BORE, DIAMETER <br /> d'Other p PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> Te%-P- L !1VAL [ON E CON UCTI SP1 C CAT S <br /> , MONITORING HOLLOW STEM 01A_OF BOREHOLE <br /> ___T`Q M LTIi'LE CASINGS 11MULTI-LEVEL WELL CASING DIFF 2'r <br /> 11 EXTRACTION 11 AIR HAMMERIDRIVEN CASING THICtCNESS 'O `e TYPE OF CASING: p STEEL VO <br /> 11 VAPOR V MUD ROTARY D OTHER: <br /> DEPTH OF GROUT SEAL /—�f3 J=MIE TYPE TO BE S ,$UGERS IJ N05E <br /> ^^ AIR SPARGE1ING OZONE 4115 ppllyT{GP or CPT)GROUT SEAL PUMPED:)v" 9 H NDTE;MAXIMUM FREE-FALL DEPTH i5 3Q') <br /> F _.'SOIL 60RIIVG 0 HAND AUGER GROUP SPECIFICATIONSL6 <br /> [I SER'-------� OTHER APPROX BORING DEPTH <br /> t7LTED TRAFFIC 13OX or a STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOS D �Of YES.115t specifications In comment saCtjon) <br /> NOTE: OFFSITE BORINGS RIEQUIRE ACCESS AGRE MENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin <br /> County Ordinances,RUIesAfidRegulations, and all applicable Calif rnla State Laws. <br /> Signed x T+tlelGompan a r <br /> Print Narne KP - <br /> Date .� <br /> DEPARTMENT USE NLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Appliration Accepted 8y {d Date issued <br /> Grout"''action lay er <br /> Date Final Insp on By Date <br /> DgSiructiarl inspection By bate <br /> COMMENTS I CONAIT1aNS: <br /> ACCOUNTING ONLY: AID# <br /> 1=AC# <br /> PE CODES !FEE INFO AMOUNT'RE1i4lT7ED CHECK# RECD BY DTE EF <br /> SERVICE Rl=Wt1EST# INVOICE <br /> Q 35-711:K IJCc_ j z aS-7 <br /> a7 WCwWAIVER C-57 Letter of Authorization to sig I permit Encroachment doc 9130/02 <br />