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64/264 14 17 2094683433 FIFTH FLOOR ] S Fz. q�4�� <br /> f! i 1 <br /> WELL, rCRMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> Mss 304 E_ Weber, Third Floor, Stockton, CA , 95202 <br /> UNIT IW <br /> (209) 468.3 €49 <br /> NON-REFUNDABLE PERMIT EXPIRES I YeAR FROM❑ATE ISSUED <br /> Application Is hereby made to San Joaquin County far a perrr t to construct and/or install the work d=_scribed This application IS made in compliance with San <br /> Joaquin County Development Title Cbapter9 I;15 3 and the Standaxds of San Joay County Environmental Health Department J <br /> WELL Location L__�Q J _Cress Sireatiqlx=_11tcityr�4Zip 3�iO Parcefti G!/ <br /> PROPIrRT c`«' <br /> Owner ,yrf�,'`- -��q <br /> Adcres& �'�J I�, City �GLU rifO ZiP ,�Phone� /+' � <br /> C-57 Contractor�c]_ 1#1 -Sc~60 Address,e/SU � � ._ } `�r�l�'Z �s a�r`i ���` tf 2�) 3 -.Eo7D <br /> ! Cr-i�t Zi hone4 �� <br /> Consultant I Sub Cntr S re vS �VL v Atldress 3 a r yt <br /> V <br /> Ci y <br /> GIS Coordinates X Y � Township_ 1_5 F'R-an9e Sectlan � <br /> 6RK TO 6E PERFDRMED <br /> NEW WELL I BORINGCPT,GEOP OSE, HYDRCC}}PUNCH HAND AUGER OTHER-) p DESTRUCTION (choose type bolow) <br /> SOIL 6bRlNG „-C <br /> p OVER BORA DIAMETER_ <br /> DWELL#� p PRESSURE GROUT - <br /> 0'Otner GROUT SPaCIFICATIONS <br /> COMMENTS - <br /> TYPE OF WELL INSTALLATION TYPE= CONSTRU TION SPECIFICATIONS <br /> [I MCWTORING 0 HOLLOW STEM DIA OF SCREHQLE_�Ln f]MULTIPLE CASINGS Q MULTI LEV=L WELL CASING DIA <br /> a EXTRACTION 11 AIR HAMMER/ORIVEN CASING THICKNESS TYPE O=CASING a STEE=L o PVC p OTHER <br /> 0 VAPOR U MUD R07ARY DEPTH OF GROUT SEAL_TREMIE TYPE TO BE USED D AUGERS 0 HOSE <br /> 0 Alr"t SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED a Yes Q No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 6iAND AUGER GROUT SPECIFICATIONS <br /> Et OTHER p OTHER_--_ APPROX BORING DEPTH Yr 9OLTED TRAFFIC BOX or STOVE PfPE <br /> CONpUCTOR CASING PROPpSED (if YES list saacifiea'ionz in comment section} <br /> COMMENTSi 1 <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 appltcabon and that the work will be done In accordance wsth San Joaquin <br /> CountA03rdot ces, Rules a ReIatlonSSf�,, aa�nd all applicable Galiforn StateLaawsSigned .�1 �"`-`/ Title/CompanPrint Napt 60 r' 64- R-67 Date e <br /> � ZI <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE, ADDRESS l �0 0 man <br /> WORK PLAN DA'T'EDa7 L_3 _3 <br /> Application Accepted By Date Issued ? _ _ Arez '2) <br /> Grout Inspection By T 'Date Final Inspectron By Date <br /> Destruction rnspeotion By Date <br /> COMMENTS I CONDrTIONS <br /> 4j;011Tl1lG ONLY A!D>m FAC# <br /> S F-EE INFO AMOUNT REMITTED CHECK# FREUD SY DATE: PERMITI SERVICE REQUEST# INVOICE <br /> � I S SR# -3_7'9j6 <br /> C-57 W�-WATVEP_ C-57 Letter or Authorimri❑r: 'to Sign parmltrT cncroac -Meni doc_ 9/30/02 <br />