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i <br /> C(DPY <br /> WELL PERMIT APPLICATION FORM <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-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicabon is hereby made to San Joaquin County for a permit to ronstruct and/or instali the work described This appiication is mane in camonanee wrth San <br /> Joaquin County Development Title Chapter 9-1115 3 and the Smndards of San Joaquin County Environmental Health Department. <br /> q,, Assessors <br /> WELL Location CJ Gross StreetY t2 4 of IL���"_City��L1�"�-Z9p 5415 Parcel J-43 Q� <br /> PROPE TY <br /> Oily Q Z�n _Phone� <br /> Owner 3 �P�daress �l _ }�� �-- -� <br /> n 3/03 Q r ,t Ct Zsp �L X145 Pnoneral(n-[{1�llJD <br /> G 57 Contractor/. { n Address jj ty <br /> Phone-E <br /> Consultant l Sub Cntr <br /> n p l7i(Y��— SecFion_��} <br /> GIS Coordinates X 3� � "3D Y,',l al +���� i ownshi <br /> WORKTO BE PERFORMED <br /> ONEW WELL I BORING (CPT GEOPR06E HYDROPUNCI-i HAND-AUG=R OTHER`] l]DESTRDIAMETER.—(choose type below) <br /> 0 SOIL BORING ri 1}OVER-BORE DIAMETER <br /> U PRESSUR-GROUT <br /> 0' <br /> GROUT S°EECIFICATiONS <br /> Other <br /> COMMENTS <br /> TYPE O7::WELL INSTALLATION TYDECONS7PUCTION SDECi (CATIONS <br /> MULTI-LEVWL WELL CASING DIA <br /> 0 MONITORING ^1riOLLOW STEM DIA 0=BOR=HOLE P`� 0 MULTI-LE CASINGS <br /> 0 <br /> CTION !1l FAIR HAMM'EI UDRNHI -11 <br /> EN CASING TCKNESS_C_ �1 a_ 1�E OAF CASING j]S i cEL PVC OTHER <br /> 0 MUD ROTARY DEPTLI OF GROfF SEALft -`f'-Gal �i6 �' EMIEiYPETO BE USED 0 AUGERS HOS= <br /> -AIR SaARGE1 OZONE 0 PUSH POINT(GD or CPT)GROUT S=AL 71UMDSD es p No (NOTE MAXIMUM FREE-FALL DEFT l5 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SaECI=ICATIONS E <br /> a _ �_ c7 jd0,icD TRAFFIC BOX a- 0 STOVE mIDE <br /> 0 OTHER D OTHER A PROK BORING DEP i�i <br /> CONDUCTOR CASING;::'r"2ODOSED i - (If YES list speancatians in comment section) <br /> COMMENTS <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 thts application and that the work will be done in accordance with San Joaquin <br /> County Orair�a s, es and Regulations, and all applicable California <br /> aarState Laves <br /> cfG DrrII n telCorrpany (�ccS �� f! l( I ►'� q _ <br /> Signer x f �^�^1[,1' <br /> 21- <br /> Print Name C r� /� Date / D -u / — <br /> 17Ef�F<TI�CINT ISE ON�.�` <br /> Z-16/40SITE MAP IN UNIT N FILE,AQ R SS <br /> 'o <br /> WORK PLAN DATED 0 "~ <br /> Acolicafion Accepted Hy <br /> Date Issued Z Area <br /> Grout Inspection Hy <br /> Date Final lnspecbon By Date <br /> Destrucuon Inspection By Dam- <br /> COMMENTS 1 CONDrnDNS <br /> i <br /> Crlou v TING ONILYAID# FACT <br /> - - - 7 i �RtitIT 1 SEP•Lr10E RE0U FEST r INIVDICE i <br /> c CODES FEE IN=O AMOU T REMiiiiEli ChECKf ) REC'D BY RAI- P` <br /> t SR# <br /> C-57 WC �-WAIVE€ C-57 Le mer o-,' Atlrhori=-,ion io siari aerrn Encroochr)enT ooc 9/3{D/C32 <br />