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2003 ,.,, 11 21AM tu, CT " 'i EARTH TECHNOLOGIES„� jo • 3098,P . 5 / 6,
<br /> WELL PERMIT APPLICATION FORM SITE
<br /> SAN JOAQl11N COUNTY PUBLIC HEALTH SERVICES MITIGATIONUNIT IV '
<br /> ENVIRONMENTAL HEALTH DIVISION (PMS-EMD)
<br /> 304 E. Weber, Third Floor, Stockton, CA., 95202
<br /> (209) 468-3449
<br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED
<br /> Applic fion is hereby made to San Joaquin County for a permit to construct and/or install the work described, This application is made In campllance with Son
<br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Envlmnmental Health Division,
<br /> Assess rs„
<br /> WELLLocation_ EV 'u" lya flvevnve- Cross Street , Yt- Vf'. City5bLc crn Zip Parcel#�u�-
<br /> PROPERTY Owner ��11 t-1y O (� C L �+ o`,, - Put IIs, K6
<br /> i�M Y JTOG :I'O„✓i Address I : f �.,�,,.Clty,,,�tieGlG�7�V� &203 Phcne# (pa,�
<br /> a,b
<br /> C57 Contractor�]Ly.,D,l-' `t1rL0 .' lddress_ 100 �F�',(y, �',�, „,_,,,City - av� Xlp9Sb'IILic#�a 49Ph X7'"7 � '�101?
<br /> Consultant I Sub Can”otorrppdor�Ta Sh T_-___ e ,_cf+.. 4ddressJ g q,q, ( Ity {,'?o-k�h Uc# Phone# oZ34�C� lg
<br /> $tri• z
<br /> GIS Coordinates: X ....._., Y., Township 12 U Range"J(0�_M,_ Section C11
<br /> WORK Tb HE R
<br /> EW WELL/ BORING ( CPT, GEOPROBE, HYORCPUNCH, HAND-AUGER, OTHER`) U DESTRUCTION (choose type below)
<br /> l) SOIL BORING # a OVERBORE
<br /> () WELL # - _. p PRESSURE GROUT
<br /> •other: /L{,lh nL+0T t Aa, ,eja,-� Grout Specificadoric,.
<br /> COMMENTS;
<br /> YYEE OF WELL yj i3INSTALLATION TYPE CONSTRU"ON SPECIFICATIONS
<br /> COONITORING OLLOW STEM DIA. OF SOREHOLE._J_�. MULTIPLE CASINGS? J YES ONO WELL CASING DIA:
<br /> p EXTRACTION U AIR HAMMERIORIVEN CASING THICKNESS 3ch• 40 TYPE OF CASING: O MEL )&G U OTHER:
<br /> 1] VAPOR U MUD ROTARY DEPTH OF GROUT SFAL4 �aq ' _ TREMW TYPE TO BE USED: WAUGERS p HOSE
<br /> o AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: 1] Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301)
<br /> U SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS;_ Neat wi
<br /> a OTHER; N OTHER APPROX, BORING DEPTHBOLTED TRAFFIC BOX or 0 STOVE PIPE
<br /> CONDUCTOR CASING PROPOSED; ( i Yz z' list spectfleailana here):
<br /> `COMMENTS
<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 /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin
<br /> County Ordinances, Rules and Regulations, and all applicable California State Laws.
<br /> Signed x Titie/Company,.
<br /> Print Name Date _
<br /> DEPARTMENT USE ONLY
<br /> SITE MAP IN UNIT IV FILE, ADDRESS :
<br /> WORK PLAN DATED :
<br /> Application Accepted By _ _ Date Issued Area___,_
<br /> Grout Inspection By... _ _ Pate Final Inspection By
<br /> e.3A ction Inspection Fay _ _ Date
<br /> COMMENTS / CONDRIONS: _ _
<br /> ACCOUNTING ONLY: AID#
<br /> PE CODES I FEE INFD AMOUNT REMITTED GHCK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE
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