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WELL PERMIT APPLICATION FORM SITE F <br /> VA <br /> _ ,:.... o TION <br /> ,,• , ... .� •SAN JOAQUIN COUNTY. . �C�,U, <br /> L HEALTH DEPARTMENT (EHD� <br /> ENVIRONMENTAL <br /> Ole . 1Neber`Th9rd Floor, Stockton, CA., 95202 JANA 1 7003 <br /> -304 E , . . .� _ . OIJ0- w D <br /> (209} 468-3449 <br /> ENVIR0Wt:N[ hrE_I <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct Standards at San Joaquin County Environmental the work . TisHealthplic on s m e in m lance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 11 <br /> theAssessors <br /> f G76 C,�u �G Parcel# <br /> I D Cross Street M,t�a^ City ZP9 <br /> WELL Location , <br /> PROPERTY Owner�tct, ,ez <br /> _Address 3 � / City !ac-II1� Zip2o3 Phone#_2�/ <br /> t rZiP9t xr'LAG#S!� Phone#_2 9 <br /> City S74' �6r�7IZ <br /> C-57 Contractor J �- Address,^ 3 65[L — /[ /�� <br /> Address /3 E � City ---.-' c# L/3�Phone#r30 66�p <br /> Consultant I Sub Contractor <br /> �6 ,ay�1 /l% Range 6 ction <br /> GIS Coordinates:XV-1 I /Q jy; ,Y N� S� Townshi P <br /> PERFORMED: _ DESTRUCTION(ch a type below). <br /> WORK TO 9E <br /> d NEW WELL I BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER') w R-BORE <br /> SOIL BORING# _ PRESSU GROUT <br /> [] <br /> WELL# Grout Specifications: ?"&t S <br /> "Other: fl-All Aw <br /> COMMENTS: G!i ac.tr <br /> TYPE F WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?[I YES [I NO WELL CASING DIA: i <br /> a MONITORING 17HIC TYPE OF CASING: Q STEEL. 0 PVC '17 OTHER. <br /> — <br /> a EXTRACTION Q AIR HAMMERIDRIVEN CASING F.GRO GROUT <br /> SEAL TREMIE TYPE TO BE USED: p AUGERS a HOSE <br /> []VAPOR U MUD ROTARY DEPTH OF GROUT SEAL <br /> Q AIR SPARGE PUSH POINT GROUT SEAL PUMPED: U Yes p No (NOTE: MAXIMUM !=REE-FALL DEPTH 1S 30') <br /> GROUT SPECIFICATIONS: <br /> Q SOIL BORING n HAND AUGER _ <br /> APPROX.BORING DEPTH 3� 13 BOLTED TRAFFIC BOX or []STOVE PIPE <br /> 1]OTHER:_�4 OTHER ations here): <br /> CONDUCTOR CASING PROPO ED? (if YES,list specifici <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS ENCROACHMENT <br /> AOR ALL R QUIRED IINSPEC SONS. <br /> CALL THE UNIT IV 1NSPECTOR 4a WORKING HOURS IN <br /> application and that the work will be done in accordance with San Joaquin <br /> hereby certify that I have prepared this app w w <br /> County Ordinances,Rules and Regulations,and all applicable California State Laws. <br /> _- Ti11e1CompanV <br /> Signed 6 J <br /> pate /,I- <br /> Print Na C �tRtDEPARTMENT USE ONLY: <br /> ." .. ..n1aa ;-^ t "..'S f: r�.s.. ....•i e ~" �i..� k.r:Y rog, 4.- ^{Si: [=. i��i.:: �e���.ii"'.+�+i} <br /> SITE MAP IN <br /> UNIT IV FILE,ADDRESS: <br /> WORK PLANRATED: N �p�/5 �. R- '?}..�.-_� , _ ���2 03 __ grew <br /> Date Issued Q = <br /> ' Application Accepted By _ _ _. r� Final Inspection B Date <br /> Date ��. <br /> Grout Inspection By <br /> x,_ .-Date <br /> Destruedon Inspection By <br /> r <br /> i COMMENTS I CONDITIONS: ,, a: �. x; �,x ht�.7 rj tr-j 4"la €: <br /> AID# C6f`ft _..ti .h0 1 •"d°fE � _"+ �� r <br /> ( ACCOUNTING ONLY: __ <br /> PE COD1=S FEE INFO AMOUNT REMITTED CHECK" <br /> - RECD BY t)Iti� w� PERMIT!5ERVICE REDUE 11dVOIC <br /> u 00 2,40 <br /> SDS 1111D <br /> SIR <br /> C-57 WC ✓ -WAIVE <br /> R C�57 Letter of Authorization to sign permit Encroachment doc A' 1l25' <br /> II, 1i <br />