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SAN–OJRNW�9.20045 6:07PMEcis DME17Li111163 0%0 E37 4574 415 955 904055 P.2 <br /> 510 297 4574 1 P'P 2 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON.REF INOA L!aEQMIT EXPIR c tyl=ao con <br /> A IlCepon is hsryb meaO to Sa Joa uhf Count for e R DATE IS IQ <br /> PP Y n q Y P mill to construct and/or Install Ina work aeecnnep. This apPlloerlon Is made in compliance with San <br /> JOaquln Gognty Development Title Chapter 9-1115 8 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Locatlen'1Q4 �i =SLAS <br /> 1fdT $7' Cross StrE.et $rClly lctp Assessors /� 001 <br /> 1� �- �41p9��Ptlreel#PROPERTY Owrter Ar.I Address Y85 Et.Ds(LA00 sq- CltY–�t—w(A I zl,.,pS2n. P xa <br /> C-57 Conrraglor t^P 10 e� pR honek_%&j 1 b7 <br /> 5fz t <br /> 5 <br /> SAMA tgtldfess ►4aa . . <br /> 0R r1 MaGR� CItY QV I Pnone#— <br /> Consult1n0Sub Cntr "'r'��rrEu.' 7Ce ���,�,y� `�`S' OtC5 <br /> '� �Aodress-S55 MpyT6.eat�Qi Ctly�WiNCtYulidf P2 S1YSt9 PheneR- 40Y d <br /> 01$Cocrpinalep,k Y Township Range Seetlon <br /> WORN TO BE PERFORMED: <br /> Q NEW WELL f BORING(CPT.GECPROSE, HYDRCPUNCH.HAND•AUGER,OTHER") p DESTRUCTION(choose type below) <br /> XSOIL BORING 9 Z% —(4 -Tuan.%.—%4 ,_ly D OVER-BORE <br /> 'Other: Wt-Ll.il0 PRESSURE GROUT <br /> COMMENTS Grout Spedflcalloda: <br /> TYPE OF WELL II'S,TALLATION TYPE CONSTRUCTION P nieICATIONS <br /> a MONITORING 0 HOLLOW STEM DIA OF SOREHOLH MULTIPLE CASINGS7 0 YES 0 NO WELL CASING DIA-_ <br /> 0 EXTRACTION 0 AIR HAMMERIORIVEN CASING THICKNESS TYPE OF CASING, n STEEL 0 PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE OPUSH POINT GROUT SEAL PUMPED n Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH 13 30') <br /> $SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER._U OTHER APPROX BORING D&PTH 0 BOLTED TRAFFIC EOX or 0 STOVE PIPE <br /> of CONDUCTOR CASING PROPOSED? (If YES,list spaoi(lastlons here) <br /> 'COMMENTS: ` DIA. 2bAkA6s T��� c�R.� t�ktAw F,RaJ.sa� �S�FtRC� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County es, Rulas and Regulation,,,and all applicable California State L/aws.//..' <br /> Sloned TIfIeIComPany �� set:T Lr�'��`c !L'�; a <br /> Print Name <br /> e f PJI^ Da10 r�"/eY <br /> DEPARTMENT USE ON Y �/ <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> ftRK PLAN DATED: <br /> Application Accepted By Data Issued Jti� Z. TGrea <br /> Grout Inspection By Date Final Inspection By Date <br /> Dealrurtron Inspacrlon By para <br /> COMMENTS4CONDITIONS; 5 r S <br /> ACCOUNTING ONLY: AIDW <br /> PE CODE$ FEE INFO AMOUNT REMITTED CHECK tr REC' PATE PMRMITI SERVICE REQUEST N INVOICE <br /> �l6 85.0IMC 10 611 3 _ 2 <br /> G�57^ <br /> WC. •WAIVER-_ C-57 Letter of Autho l 0 sign perknit_Encroachment doc^ 1/25/02 <br />