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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 /> WELL Location -1'rc Assessors <br /> (aTne%. Cross Street L 6vi c`_. 4"� <br /> x 7 AJ-1J ty _zp 7$ 7� Parcel# <br /> PROPERTY Owner 'DD1C-TraG/ Address ikop Cl�rist,�a �Cm, J'tra TZp 85376 Phone# 904-23q_ yoy <br /> C-57 Contractor �rv'e49�r;1(= /I,ddess 9r�p t}n�e Qmd City Mild ez Zpg450Lic# 4 51L Sphone# 313•- $Op <br /> Consultant/9ob�enireeter UpS r ra}, Address a �a Pr, Sa'J¢3oo <br /> P -�k_�a _Ciity 5Grr,..�nkLicIf Phone# 9(14-6"79$1)00 <br /> GIS Coordinates:X ,Y ,Townshi <br /> P Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,(?AND-AUGER,OTHER") w6E/ <br /> STRUCTION(choose type below) <br /> D SOIL BORING# <br /> H WELL# IIyoVER-BORE <br /> 'Other: I�ESSURE GROUT <br /> COMMENTS. Grout Specifications: Sce_ llpv\9 V, <br /> See 0.k1at_1�cd t-�ryr'1L�l�n � al,,,,,,,,t � ! a•fr -1'PZ\ TPz10 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING p•fIOLLOW STEM DIA.OF BOREHOLE (o It MULTIPLE CASINGS YES �� t <br /> : Ko WELL CASING DIA <br /> 0 EXTRACTION <br /> 0 AIR HAMMER/DRIVEN CASING THICKNESSSc.V�• 40 TYPE OF CASING: n STEEL 0,15VC 0 OTHER: <br /> n VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL PREMIE TYPE TO BE US <br /> ED D ANGERS n HOSE <br /> 0 AIR SPARGE n PUSH POINT GROUT SEAL PUMPED: - ,'Is UN. (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> n SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 'Ty be�ff?�,}1a not V4 jy 1. 'bir{uI Ie, ml K <br /> IrtTHER: 0 OTHER APPROX.BORING DEPTH ^3?-52_r bc,_S 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: b - S fp o 1 c-lt <br /> O.rKt byr�l-,...i 40 ,5�n f.- Og ,C 1. n\, ir� Iledondrx� A- i+- W-j1 1(6 <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHM T PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Title/Company •Q <br /> -��— Car' o w <br /> Print Name S0. Tc.r�rre Date 11131 bL4 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By LC _ _Date Issued 0 _Area q 97 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> cnru <br /> [PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a9•Oz &600 60. 00 355-?-21 lJk TJ ,o sR# oo l <br /> r-67 Wf -%A1ATt/CD r c�r _.. <br />