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WELLWERMIT APPLICATION FCOM SITE <br /> SAN JOAQUIN COUNTY <br /> ,��"':­�',' IVIITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT I-V <br /> (209) 468-3449 <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 1s:made,mqompli6h 6e with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> '5o,A4 U5 5.(ktoKef L4nt Lod.I ,tV�, Assessors <br /> WELL Location S-1deuja Cross Street City <br /> Lo�,j Zip q5i�qO Parcel# Yllq <br /> V <br /> PROPERTY <br /> Owner C-164, L4)dl Address U W61 P.)q S+,, City­j� Ui -Zip to'MO Phone# (kl) 333-43,V <br /> C-57 ContractorV4j. Df-%V1A1,�),Ac1d,,,, -city Ri 4 Mti-zipi-q-511-ic#1�7 Phone#70-7-37V-Y-30t, <br /> Consultant/Sub Cntrs�rA5 rhAvir i �A(. 0!55*0 City6,-Mthn Pad`Laic '5"Z Ph...#( <br /> DA 4"W, Address Mfrjv\ <br /> GIS Coordinates:X -Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,V,NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER') DESTRUCTION (choose type below) <br /> 0 SOIL BORING# OVER-BORE. <br /> DIAMETER WELL# t -1 jmul-�VW-41 A <br /> ft) W-9 PRESSURE GROUT <br /> *Other GROUT <br /> SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XMONITORING )(HOLLOW STEM DIA.OF BOREHOLEK 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:Z <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5d4,Lfo PC TYPE OF CASING: []STEEL )kPVC []OTHER: <br /> []VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ySr TREMIE TYPE TO BE USED: ) AUGERS HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )I(Yes 0 No NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> [] SOIL BORING HAND AUGER GROUT SPECIFICATIONS Old QM'J <br /> []OTHER:_[]OTHER_____-.-----. APPROX.BORING DEPTH 70' TRAFFIC BOX or []STOVEPIPE <br /> CONDUCTOR CASING PROPOSED— t1D (if YES,list specifications in comment section) <br /> COMMENTS: <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x � 1--,� Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> C kul; <br /> SITE MAP IN UNIT IV FILE, ADDRESI'. <br /> WORK PLAN DATED: <br /> Application Accented <br /> oted By Date Issued Area 2-- <br /> Grout Inspection By �M (Aate Final Inspection By <br /> Date <br /> DestructionInspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES AMOUNT REMITTED I CHECK# REC'D BYDATEPERMIT SERVICE REQUEST# f INVOICE <br /> 0 0 7-41- [1467 s,Q� qJ591 <br />