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WELIOPERMIT APPLICATION ARM <br /> OCT 2 2006 SAN JOAQUIN COUNTY SITE <br /> U�� VIRONMENT HEALTH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> PERMITIR�ICES 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Locationk l3`05 A <br /> ssessors <br /> PROPERTY Street city WL of Zipp5Q37 Parcel# <br /> 0. 5 ' I L Owner_ S4 <br /> Address-* C� y PPhone# rx%✓" aj y_ <br /> C-57 Contractor it �r li Evl�. Address 233.5 [.Iti IQs � Cit e: jrd ISS 1 <br /> 1 Y Zip �YG Lic# 1 Phone#�D]-yyy�(}yV <br /> Consultant/Sub Cntr�1� ✓►�',-�,,��Adddress�53G} &Mj t,1 P! a'i�(55V COT-ffrWl � �� `%5(o Z <br /> Lic# Phone# 530_b 74'-A6-e <br /> GIS Coordinates:X 'Y ,Township Range 9 Section <br /> W RK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# <br /> DIAMETER 0 OVER-BORE. <br /> 0 WELL <br /> 0'Other PRESSURE GROUT <br /> SPECIFICATIONS ff I [ GROUT <br /> COMMENTS: I J� ,� 5 � 60' nc1 ro IL'L tl{C1'� <br /> TYPE_ OF WELL IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING HOLLOW STEM DIA.OF BOREHOLE " MULTIPLE CASINGS <br /> �— � []MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 11"/t1 <br /> TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> AUGERS 0 <br /> 0 AIR SPARGE/OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED:X Yes V ,NoI(NOTE! MAXIMUM FREE-E TYPE TO BE USED: TALL DEPTH HOSE <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS n 6-4A-7yyv�,yl� S 30') <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH C <br /> 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING PROPOSED 6D (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�l this application and that the work will be done in accordance with San Joaquin <br /> County Ordina es/Rules a g latio and all applicable California State Law . <br /> (/ <br /> Signed x r <br /> Title/Company Q <br /> Print Name <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRSS: <br /> WORK PLAN DATED: 1-, ()(, <br /> Application Accepted Date Issued <br /> Grout Inspection By ( Area <br /> Date f )�> Final Inspection By <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> ( FAC# <br /> I PE CODES TFEE INFO AMOUNT REMITTED TCHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> Z CUs— _5I�D0�i'xF OO <br />