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2094' -1433 EHD PAGE 02 <br /> WELL PERMIT APPLICATION FORM _i Op & 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 Q-.e woo <br /> ON-REFUND BLE PERMR EXPIRF-S 1�YEARthe QFk d��h�' appliCalion is made in Compliance W <br /> Application is hereby made to San JodQuin County for a permit to construct and/or <br /> Joaquin County Development"Mil- r�hatyter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department AssemsDm <br /> Cross Street �;P"! � City <br /> 23, Qsz3 v Parcel#, o��-— <br /> W <br /> ELL Localton l�7 <br /> n1 ply i L" j- City r`�t-jq�y Phone# 112 <br /> ��S Address <br /> PROPERTY Owner 3 t/• 42-brel��Y? �5 3 �;„�: t h%c city.k•i:�, zp!jLl 7 u� <br /> C�67 Contracbx_ <br /> Consultant J Sub Cntr__U�!(— Address <br /> GIS Coordinates:X 'Y <br /> Township Range Section <br /> WORK T SE PERFORM D: <br /> �NEW W LL 1 BORING (CPT,GEOPROBE,HYDROPUNcH,HAND--AUGER OTHER') p DESTRUCTION (choose type below) <br /> "OIL BORING# n PRESSURE <br /> E• DIAfv1El ER <br /> p PRESSURE GROUT <br /> p WELL# II GROUT SPECIFICATIONS <br /> COMMENTS: t - ' <br /> TYPE OF WEL INSTAU ATIaN T_Yt_'E CONSTRUCTION SPECIFICAMOUtTIPLEEASINGS 0 MULTI-L'vEL WE'_L CASING Dim <br /> Q MONITORING OLLOW STEM DIA.OF BOREHOLE 0 PVC OTfJ_r:: <br /> OF CASING: n ST-_L p <br /> 0 (TRACTION /p AIR HAMMERIDRIVEN CASING THICKNFSS TYPETREMIE TYP*TO 6E USeD: UGERS Q n05cJPVL <br /> Q VAPOR �]MUD ROTARY DEPTH OF GROUT SEAL <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes d No (N TE: MAXIMUM FREFAL DEPTH IS 3Q'j <br /> OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> OTHER APPROX BORING DEPTH-� ( 11 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> 0 OTHER:s�� rf YES.list speciflcatlons in p,mmentsedion) <br /> CONDUCTOR CASING PROPOSED c <br /> COMMENTS.'— <br /> NOTE: <br /> OMMENTS:NOTE: OFFSITE BORINGS REQUIRE ACCESS SQUIRED FOR INSPECTIONS. <br /> ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NO <br /> I hereby certify that I have prepared hi anspiicatio l and <br /> that <br /> the <br /> Ca oro ill be done in Laves. accordance W;th San JoaquiO <br /> County Ordma s,Rules app <br /> Tide/Company. <br /> Signed <br /> G . 6'1�--�(4�c�sl�` Date <br /> Paint Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED= <br /> Date Issued, <br /> Area <br /> Appliczlion Accepted 13 Inspection By <br /> Dat< <br /> Grout rn3pe0tlon By <br /> Date, Pinal <br /> Oostrucdon In3pecton By 6)Date <br /> l <br /> COMMENTS/CONDMONS: NoAh <br /> ACCOUNTING ONLY: AID# FAC# <br /> FE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE F S�1 SERVICE REQUEST# INVOICE <br /> 41 <br /> C-57_ WC;WAIVER C-57 Letter of Authorizatioh to Sign permit,Encroachment doc— <br /> yi 30102 <br />