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ERMIT APPLICATION F�M <br /> . SITE <br /> SAN JOAQUIN COUNTY . <br /> JAN 1 7 200 MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> ENVIRONMENTE. Weber Third Floor Stockton, UNIT 1V <br /> to CA. 952 <br /> HEAD' , , , 02 <br /> i <br /> PERMIT/SERVICES (209) 4683449 <br /> NON-REFUNDABLE PERMIT EXPIRES.1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlorinstall the work described. This appiication.is made in compliance with'San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 3o SOURAW. ii Assessors I <br /> WELL Location + 5� Cross Street W City 5 �i� i Zip Parcel#. <br /> PROPERTY /� I p1 <br /> Owner ARU AddreA "Oi r . . City lAPKhm Zip 104B Phone# G;?:C p- /444035 <br /> ff <br /> C-57 Contractor r s Address �6 J�ay� IJOL ICG[, nn City / f Zip q;F Lic#.'"51 Phone# �2S'3��,�5�� <br /> Consultant I Sub Cntr A Add sss �m 1 t/t� City L`"" t'' qsb PZ Phone# - 4- <br /> pdp <br /> GIS Coordinates:X Y. Township Range . Section 1 <br /> +} `WO.RK TO BE PERFORMED: <br /> A`NEW WELL I BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,.OTHER-) (] DESTRUCTION (choose,type below) <br /> ' o SOIL BORING# 0 OVER-BORE. <br /> DIAMETER <br /> WNELL# W— - 0 PRESSURE GROUT <br /> 11"Other GROUT <br /> SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �{ <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE 10" a MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS5L4. V TYPE OF CASING: 0 STEEL VC p OTHER: <br /> a VAPOR []MUD ROTARY DEPTH OF GROUT SEAL � TREMIE TYPE TO BE USED:. k.UGERS a HOSE <br /> H AIR SPARGE/OZONE G PUSH POINT(GP or CPT)GROUT SEAL PUMPED: U Yes Xlo (NOTE: 'M IMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING p HAND AUGER GROUT SPECIFICATIONS_Af4 � <br /> [I OTHER: fl OTHER APPROX.BORING DEPTH 53' 'WOLTED TRAFFIC BOX or.a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED AO (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS.- <br /> 48 <br /> ERMITS:48 WORKING HOURS NOTICE REQUIRED FOR.INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi ces u a tions, and all applicable California State Laws. <br /> Signed x Titlell <br /> elCompany G� /Pj��C�/I ell, <br /> Print Name .. Date / <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By b:rrCe rs as 7 Date Issued Area I7`5 <br /> Grout Inspection By Date Final Inspection By <br /> Date <br /> Destruction.Inspection By Date - <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# R 00,q5-774.1 <br /> PE CODES FEE INFO AMOUNT REMITTED. CHECK# B�U� REC'D BY' DATE PERMIT I SERVICE REQUEST# INVOICE <br /> u <br />