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09/02/2005 08 20 2094683433 EHD PAGE 02 <br /> WELL PERMIT APPLICATION FORM 1 <br /> SAN JOAQUIN COUNTY MITIGATION <br /> i ENVIRONMENTAL HEALTH DEPARTMENT (!~HD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT 1V <br /> (209) 463,3449 <br /> NONzBEFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT i ISSUED <br /> Appltcahon is hereby made to San Joaquin County fbr a permit to Construct and/or install the work described This application i5 made In vOmplianCe with San <br /> Joaquin County Development Tide.Chapter9-11153I and the Standards of San Joaquin OOunty Enhronmental Health Department <br /> WELL Location °� h* � jr <br /> 6A Cross StreetAssessors <br /> , City � �D parcel# <br /> lPROPE TY (In SjatlFwq I K bi Q�PkiS Zip r155) ._ <br /> Owner e5 l�� ■a51�_AddreSs 0 c done a u City p� Phone# 0 _a i1-'9T.G� <br /> Cv^l Cgntractor, f _Adddress Crty bP_ zip l LIC �J� �Phone# <br /> 0,p <br /> Consultant/Sub Ontr P 1 9Na1+F1 Address 4 � <Ctty�fPhone# �/��p?pj,,� <br /> GIS Coordinates X Y ,Townsh �t <br /> P— Range Section <br /> VW011,RK TG BE PERFORMED <br /> NEW WELL/BORING CP EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) a DESTRUCTION (choose type below] <br /> SOIL BORING# - Q OVER-SORE <br /> p wEt.i� <br /> n`Other tl PRESSURE GROUT <br /> -•— GROUT SPPo <br /> COMMENTS <br /> n"P-SOF WELL INS T16ILqN TYPE CONSTRUCTION SPECIFICATIar;s <br /> U MONITORING 11 HOLLOW STEM DIA OF BOREHOLE <br /> 11 t]MULTIPLE CASINGS 11 MULTI-LEVEL WELL CASING DIA <br /> ACTION 11 AIR HAMMER/DFiNEN CASING THICKNESS 1 f TYPE OF CASING <br /> t! APOR t]STEEL Q PVC []OTHER <br /> Q MUD ROTARY DEPTH OF GROUT SEAL t7� TREMIE-TYPE TO BE USED GAUGERS d AIR 5PARGE1020NE U5OSE/ <br /> !-I POINT(GIS or CPT)GROiJT SEAL PUMPED �Yss Il No (N'OTE MA)UMUM FREE-FALL DEPTH M 34')�� <br /> SOIL OORING C1 KANO AIGER GROUT SPECIFICATIONS <br /> ]OTHER f1 OTHER APPROX BORING DEPTH i l <br /> {]BOLTED TRAFFIC 13OX or U STOVE PIPE <br /> COMMENTS CONDUCTOR CASING PROPOSED_60 (if Y85,list Specrfrcations in comment section) <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <br /> 4$WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> �atrnty Ordirr ,@,CTj9tI0nS, and all applicable California State Laws, <br /> +fined x Title/Company 111115 ,1r <br /> not Name e__&1 VPr <br /> DEPARTMENT USE ONLY <br /> LITE MAP IN UNIT I11 FILE,ADDRESS: X9 <br /> IIORK PLAN DATED: —p <br /> pplrcation Accepted By Data Issued---t-l / } <br /> rout Inspection By _Area_ <br /> _,,,,Date_ I anal Inspachon By T� <br /> e5tructiOn Inspechon By Date +�7 <br /> DUMBNTS/CONI1rrms <br /> 4 NT1NG ONLY AID# <br /> #FAC# <br /> $E CODES FEE INFQ AMOUNT REMITTED 'D BY DATE <br /> PERMIT I SERVICE REQUEST# INVOICE <br />