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FIMENED 0 <br /> WELL PERMIT APPLICATION FORM SITE <br /> OCT 2 2006 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> NORO NMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> --' PERMIT/'SEMACES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 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 /> Joaquin County Development Title,Chapter 9-1115..3r and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location A"Dw`� c y L Q� "� �1�( "� city to �e 11/� Zip 15 37 Parcel#Assessors <br /> ����� 64V �0 Cross Street i " ' Ci <br /> PROPERTY " �� `- f1' c�� 1 <br /> Owner USA (�5 �tytQ�_Address qO5 941td4; � VWj;11(6)tldCity Q b W, p�Z'p I j37j Phone# 05"°71`( ftz) <br /> C-57 Contractor I t D' Ii Fl�. Address23335 E,rAi IQs AV. City erred Zip 5i VO Lice#f l2Phone#-7d I-90 0- ) <br /> Consultant/Sub Cntrs). � fy V1 nJrlMhtFtU h&res0 m� , y�r � � �ic AJC ��Phone# �50-67I,-A("'7 <br /> GIS Coordinates:X 'Y Township Range Section <br /> W RK TO BE PERFORMED, <br /> NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. <br /> DIAMETER <br /> 0 WELL# <br /> �'Other 0 PRESSURE GROUT <br /> t I GROUT <br /> SPECIFICATIONS <br /> COMMENTS Or tH ri�G) {� ItJ1 IZi�'� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING )(HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS In let TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> TREMIE TYPE TO BE USED: /AUGERS 0 HOSE <br /> []AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:XYes No (NOTE: MAXIMUM FREE-9ALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS I'I r?l�l�y((byW b <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH (J pp�(�C12 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED 110 (if YES,list specifications in comment section) <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 prepare this application and that the work will be done in accordance with San Joaquin <br /> County Ordi" eS Rules ag latio and all applicable California State Law . <br /> Signed x Title/Company <br /> Print Name A, Date 6 2t., at <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, DDR SS:_�_��j <br /> WORK PLAN DATED: 41 --1 <br /> Application Accepted By� Date Issued Area 9 <br /> Grout Inspection By Date Final Inspection By <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FACCOUNTING ONLY: AID# FAC# <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# I INVOICE <br />