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1J1/ELL WERMIT APPLICATION FOfA <br /> SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> Fj o' 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 <br /> W <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors '043 /V6 <br /> WELL Location aerokrt L4ii( Cross Street LOal AV City /Odi �Zip 75Z7o Parcel# 49 <br /> .Y &ccrtqr&ttoG� NX0 7 L-&-We-*– <br /> PROPERTY LLI- 1 0 1 -4 <br /> 11 0 ip42j;��'h. L <br /> Owner 4e&4� Address City IcqT q I M W- (. <br /> 3 Vw <br /> C-57 Contractor Wob&m� 6, Addr... 550 R i V tj City 10 Zip�Y571 Lic#j/()0]_9 Phone# 6j)- <br /> Consultant/Sub Cntr *45 <br /> �Acl&113 <br /> #5�5Cty C4,m&M.L41 kP 1563 Z Phone#(130)06 <br /> GIS Coordinates:X Y- Township_ Range Section <br /> WORK TO BE PERFORMED: <br /> `KNEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) [] DESTRUCTION (choose type below) <br /> []SOIL BORING# OVER-BORE. <br /> DIAMETER <br /> RESF <br /> �Vll L/?-; -V P- P <br /> ' RE- <br /> 1]*Other GROUT -�ROU <br /> SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Q Aq CAPd "q M jif <br /> KN10NITORING IOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 6 & d- <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL PVC []OT bjL <br /> IKVAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE 2D: 0 AUGERS HOSE <br /> []AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes fl-,.No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING HAND AUGER GROUT SPECIFICATIONS—C.�-�� <br /> OTHER: ______XOTHER C 4r kviih APPROX.BORING DEPTH Le 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED nt .(if YES,lists ecifil in comm nt section) <br /> '1 0- <br /> COMMENTS: 50 V5 or probe W65 ii,15'411f) q&, air knir(1w4 k0dif" 1.1e. <br /> 1 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR FNCk)ACHMLNT 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x, Title/Company z,w,e, <br /> Print Name 6 IA.62 DEPARTMENT USE ONLY Date 7 <br /> SITE MAP IN UNIT IV FILE, ADDRESS: as <br /> -7---7 (o <br /> WORK PLAN DATED: 6 <br /> C-741 4Date Issued lh;�6-16 7 —Area— <br /> Application Accepted By 0iainal Inspection By <br /> Grout Inspection By to //�.43&2, <br /> Date 7- <br /> Destruction Inspection By Date <br /> COMMS-OTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK# REC'D BY I DATE PERMIT I SERVICE REQUEST# INVOICE <br />