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FILE COPY <br /> WELL PERMIT APAGATION FORM <br /> SITE <br /> SAN JOAQUIN.000NTY TION <br /> M�T�GA <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT A <br /> 304 E. Weber, Third.Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRE 1 YEAR FROM DAT 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 /> 0( <br /> Joaquin County Development <br /> '�Title,Chapter&1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location a�Ds LOV �! �!� �'��� ��� qC� Assessors <br /> _ Cross Street -S City J 1t7Gtl _Zip Parcel# <br /> PROPE ITY Cin�,dtvnt�IC bi"0i*,SQddr[35� <br /> Owner olzsw)cs (�sf �Is�in *Adft <br /> rlta ✓City iPPhone# SDS e11ysP2lJI� <br /> C-57 Contractor � , -Sj}t► Address ISD CityZip YS Lic# 514 I Phone#925 3/3-ff& <br /> Consultant I Sub CntrJryi{jd M!A AddressJD. 6*Mf&M JUPk.City I Z phone#_ �&76-ap6 Z <br /> GIS Coordinates:XSvi' 55v <br /> Y ,Township Range Section <br /> WORK TO BE PERF �D: <br /> "EW WELL/BORMG EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# OVER-BARE. <br /> Q WELL# a PRESSURE GROUT <br /> it*Other - -- � GROUT `J <br /> - _ Pte. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 11 MONITORING a HOLLOW STEM DIA.OF BOREHOLE1`r. 11 MULTIPLE CASINGS 13 MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: (I STEEL Q PVC p OTHER:_ <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL OI�� TREMIE TYPE TO BE USED: 1]AUGERS VOSE/1]AIR SPARGE/OZONE*USH POINT(GP or CPT)GROUT SEAL PUMPED:` Yes p No (NOTE:�1A)ciMUM FREE-FALL DEPTH30') <br /> AWL BORING 0 HAND AUGER GROUT SPECIFICATIONS- am-4 <br /> Q OTHER: ___n OTHER APPROX.BORING DEPTH _$D <br /> • 11 BOLTED TRAFFIC BOX or [J Sl'.OVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED 40 (if YES,list specifications in comment section) <br /> NOTE: OFFSITE'SORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordi Ions,and all applicable California State Laws. <br /> �d X / Tttie/Company I& r <br /> Print Name / // Date Q <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: - —O <br /> Application Accepted By Date issued_ r 7 -d0(�9 . <br /> Area <br /> Grout Inspection By —Date Final Inspection By <br /> Dion Inspection By Date <br /> COMMENTS/COND(TIONS:� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1 <br />