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pn(� WEDW PERMIT APPLICATION*)RM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> MAR g - 2005_ 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> NT NEALjH (209) 468-3449 <br /> Et�VpI�R�M�TERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is a y made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-111555.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 11 I I1fI+ G ` Z' Assessors <br /> WELL Location �n'(_ J IV YC•rro�ss Street �Z�J City p <br /> Parcel# 4(y` �y�� '/ G rr� <br /> POWOePERTY ; �/1_ a o/ Address •wit r3 1,Wl City Il'r�Jtt� AI Zi2�Phonne# z6-6L?Y-7/ `n <br /> C•57 ContractorC.Cl� IwM 1 fA� Address 2 A City) ccII(J''``Zip��Lic#//ZZbo Phone#1 b-i/vZ <br /> Consultant/Sub Cnlr�IPr A .IrUrO Address GVZ CityJ� b Lic# _ Phone# 7 ~ �3 <br /> GIS Coordinates:X ,Y ,Township Range <br /> Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT, 01 DROPUNCH HAND-AUGER, OTHER-) Q DESTRUCTION (choose type below) <br /> N SOIL BORING# >4 A.J�j Z 0 OVER-BORE. <br /> DIAMETER GX r _ <br /> 0 WELL# 'PRESSURE GROUT <br /> 0"Other GRO <br /> SPECIFICATIONS r/!1c 5 1 <br /> COMMENTS: s r S ZO SIS TIC <br /> i5; �it� — a le' <br /> TYPE OlVWELL INSTAL ATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING FiOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: v <br /> p EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS W TYPE OF CASING: N STEEL 0 PVC 0 OTHER: <br /> pp I <br /> I. 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL urot, +:y IE TREM TYPE TO BE USED: )/j'AUGERS HOSE UC <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT) M1 SUr w GROUT SEAL PUMPED: Pas p N ` <br /> (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> d­sOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS jj0T 6V-N I)9171dV�� S 11PN <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH FL-50 0 BOLTED TRAFFIC BO)J J STOVE PIPE <br /> - - CONDUCTOR CASING PROPOSED. __ (if YES, list specifications in comment <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify at I have p epared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi n es les nd Regulations, and all applicable California State yLaaws. <br /> Signed x Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: �j p E <br /> Application Accepted By get iimt Date <br /> Issued Area <br /> Grout Inspection By Date Final Inspection By <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEE INFO AMOUNTREMITTED CHECK# REC'O BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> IVj3? SR# V /yob <br />