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WELL. PERMIT APPLICATION FORM SITE ' <br /> - MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> JoaquinAppricabon <br /> County De a opment San riitfeJChapter 9-111'5 3 and thefor a it to construct S dards of San Joaquin County Environor install the work mental Health This 1cation is D partinen de in compliance with San <br /> Joaquin h' Assessors <br /> C& Cass Street IWItm., City Azip�Paroel# Jlji/- <br /> WELL Locaton76 Q� <br /> Address X63 �•G '�h�r¢ Crty f It p r2°3 Phone# 2 C% ' gY-1A i <br /> PROPERTY Owner� � y07 z <br /> r Address 23 s !•+ �Clty S1"n+ Zip '�Uo#SI� Phone#a <br /> C-57 Contractor J e-� <br /> (, ,+�►iJ �` ►* Address r��E"�� City�rc# 113 Phone$�30 668'.f`.a� <br /> Consultant 1 Sub Contractor r <br /> GIS Coordinates X—W— /`i>; <br /> aye Y �7°S8%��`� ,Township A/ Range__c E Section <br /> WORK TO BE PERFORMED DESTRUCTION(choose type below) <br /> (]NEW WELL 1 BORING(CPT,GEOPROBE,FiYDROPUNCH,HAND-AUGER,OTHER') ;OVER-BORE <br /> SOIL BORING# ,�y / PRESSU GROUT <br /> WELL# Grout Specifications � � �` s <br /> *Other // fy�p, Sr <br /> Comm ENTS G!i/ �ititr <br /> � INSTALLATION TYPE CONSTRUCTION SPECIFiCATiONS <br /> TYPE�LL <br /> (]MONITORING ❑HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?()YES [)NO WELL CASING DIA <br /> EXTRACTION [}AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING [)STEEL D PVC I]OTHER <br /> DE TYPE TO BE USED I]AUGERS J]HOSE <br /> !l MUD ROTARY L <br /> AIR SPARGE PUSH POINT GROUT SEAL PUMPED D yes D No (NOTE:TREMMAXIMUM FREE-FALL DEPTH IS 30' <br /> D AIR SPD <br /> D SOIL BORING (]HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER_ OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (+f YES,list specifications here) <br /> 'COMMENTS <br /> NOTE: OFFSITE BORINGS REQUiRE ACESS OR CN ADVANCE FORENCROACHMENTALL UiRED 11NSl'ECTIONS <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS <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 /> Title/CompanyV p 6 J <br /> Signed x <br /> Date <br /> Print Na G DEPARTMENT USE ONLY <br /> 1 <br /> SITE MAP 1N UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued Area <br /> Appficatlon Accepted BY Date Final Inspection By Date------ <br /> Grant Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AID# rerer <br /> p9 CODES FEE INFO AMOUNT REMrtTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> �/9GCI <br />