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' 12122/2005 16 23 2094683433 EHD PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> COPY SAN JOAQUIN COUNTY aEaE TION <br /> 6 ki ENVIRONMENTAL HEALTH DEPARTMENT (EH <br /> I�±I L 304 E. Weber, Third Floor, Stockton, CA., 98202 DEL 2 2 205- <br /> (209) 468-3449 <br /> NON REFUNDABLE PERMIT FXPIRES I YEAR FROM DATE ISS1WR0N"f[ENTH6kWiance m'[h San <br /> Application is hereby made to San Joaquin County for a permit to corns[ruct and)or Install the work described This ai�Fii <br />' Joaquin County Development Mite Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Heal g5se55ors r <br /> WELL Location S �t CrOSs Street City l ZEp 5 QJr Part~et# r ��—Q <br />' O ROerE °ddress iU ti CILyJQ [ D -zip 5O51 Phone# <br /> C-57 Contractor <br /> 6190 �3YAMAddress Crty zip �Ch+n 17� 3 <br /> } � ��tnf AdGress333D ,�,�. �r � r 1�'tr:e^LIj (A "6V e�#_ '556-67 - ',dib 2 <br />' Consultant 160 Crntr 5t( 1_ <br /> Gly Coordinates X ,Y Township Range Sachon, <br />' WORK TO BE RERFQ13MF0 <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) Q DESTRUCTION (choose type below) <br /> 11 SOILIgRING# 1fd 13 OVER-BORE <br /> DIAMETER �1 I J)eRESSURE GRO T <br /> WELL# GROUT $2N1I� S D <br />' "Other <br /> SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATI0145 <br /> U MONITORING 11 HOLLOW STEM DIA OF SOREHOLIw Z`ti`� 1n MULTIPLE CASINGS []MULTI-l_1=VEL WELL CASWG DIA <br /> JDXTPAQTION Q AIR HAMMERIDRIVEN CASING THICKNESS 1 TYPE CSF CASING U STEEL p PVC q OTHER <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT TREMIS TYPE TO BE USED GAUGERS HOSE <br /> t]PIR SPARGEI OZONE XUSM POINT(GP or CPT)GROUT SEAT_PUMPED Yes C No (NOTE, MAXIMUM FRET=-FALL DF-PTH IS 30') <br /> SOIL BORING p HAND AUGER GROUT SPECIFICATIONS - � tqvod sa rND <br /> U OTHER' _ l OTHER APPROX_BORING DEPTH S F`ISo` 80LTED TRAFFIC OX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A0 __(If YES,list specriicabons in comment sectien) <br />' COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />' I hereby certify that I have prepared this application and that the wort will be done in accordance with San Joaquin <br /> County Old i antes, R les and Regul ns, and all applicable California State Laws. <br /> Signed x Tiowcompany <br /> Print Name 1�77ti4 lc.�[l [T date I � <br /> DEPARTMENT USE ONLY <br /> 1 SITE MAP IN UNIT IV FIDE, DRSS' <br /> WORK PLAN DATED. <br />' AAplieadon Accepted By Date Issued - <br /> Grout Inspection By Date Final Inspection 9y <br />' Date <br /> Destruction inspection By Data <br /> OMMENTS l 0094DITIONS <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMn TED CHECK# REC'A BY DATE PERMIT I SERVICE REt.ZlIEST# INVOICE <br />