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-- _• cu�vgo7vJJ r1r rrr rL_UUK HA(�t. 13L <br /> D WELL PERMIT APPLICATION FORM <br /> SAN JOgQUIN COUNTY SITE <br /> 7• ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> 304 E- Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 ;�'rm <br /> Application rs here NON"REFl1Nbg13LE PER ff EXPIRES i YE R FROM XMIE ISSUED <br /> JOaguln County �`made to San Joaquin County for a permrt to construct and/or install the work described This a plication Development Title Chapter 9.11 IS 3 and the Standards of Sari um Coon Ernnronmental Health be <br /> Joaq ry pP 6or1 u made in complranca with San <br /> WELL Location S Co - - — _ _ _ parlmenL <br /> v� Cross street P I n,o �-�GVCrty — -- - Assessors <br /> PROP> 1 ZIP__ . Parcet# <br /> Ownerr •,I•�•F rc�.iRrs LGG �f <br /> °rens 4-a� r zip 77as4Phonete <br /> C-57 Contractor <br /> Addressee.c/�vcn c.e �S7 <br /> consultant ��r �.1, rte, O'�' 'p` Lrc$ YDS/CS Phone#`�lS-3l• <br /> r�8a� <br /> 'Sraar�s z � � ;.sSff tars <br /> GIS Coordwalm X Y --�WORK TO BE PERFORMED. <br /> 1ownshrp <br /> Section <br /> EWWELL!BpR1NGNc <br /> os HYDROPUNCH,�-�ry <br /> SOIL BORING# 6-/y r(Ge p„�,C +UGER•OTHER") 0 DESTRUCTION <br /> R WELL �. 5 Q OVER-BORE. DIAMETER R��type below) <br /> Il.Other C AU4�) 11 PRESSURE GROUT <br /> COMMENTS - GROUT SPECIFICATIONS <br /> TrPE OF WELL <br /> k----�, INSTALLATION TYpr- CONSTRUCTION SPECIFICATIONS <br /> M1ONITORING HOLLOW STEM! DIA OF BOREHOLE Q�r h <br /> �� {1 MULTIPLE CASINGS 11 MULTI-LEVEL WELL CASING DIA <br /> 11 EXTRACTION 0 AIR HAMMERIDRtVEt4 CASING TmICKNESS S` 4 VO <br /> B VAPORp MUD ROTARY DEPT -- ---TYPE OF CASING 11 STEEL An'pVC Q OT13EF �`` <br /> H OF GROUT SEAL `l' TREMIE TYPE TO BE USED <br /> D11 AUGERS 13 HOSE <br /> At SPARGE/020NIr�p{�Sy POINT(GP or CP i)GROUT SES_PUMPED [J Yes Np�NOTE: MAXIMUM FREE-FALL DEPTH S 3[Y) <br /> BORING 11 AND AUGER GROUT SPECIFICATIONS ! <br /> Q HER_ nOTHER <br /> APPROX.BORING DEPTH r <br /> OLTED TRAFFIC t30X or 11 STOVE PIPE <br /> COMMENTS- . <br /> CONDUCTOR CASING PROPOSED {f YES Irs(specifrcatrons m oomment section) <br /> So � � �„� <br /> NOTE: OFFSIT ORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS- <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify that I have prepared this application and that the Work will be done in accordance with San Joaquin <br /> County Ordinances u a latlons, and all applicable California State taws. <br /> Signed x <br /> 'rMe/Company <br /> Print Name � �+ � <br /> DEPARTMENT USE ONLY Cate <br /> SITE MAP 1N UNIT IV FILE,ADDRESS' zS�L <br /> NORK PLAN DATED: <br /> WILCatron A=epted 6y <br />,rout Inspeet,on BY lYa1a_ <br />'estrt,cbon Date Issued fVga � <br /> Ins Final Inspection 8y � ~• to <br /> pect;on By Date <br /> OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY AIDS <br /> FACJ! <br />°E CODES FEE INFO AMOUNT REMITTED CHECK 0 RECD 13Y DATE pERMrr!SERVICE REQUEST# INVOICE <br /> i <br /> 57 WC -WAIVER C-57 Letter of AuthcriZat+on to sign permit Encroachment doc <br /> 9/30/02 <br />