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02/09/2006 09 08 2094683433 EHD PAGE 02 <br /> MD <br /> nECHyWaLL PERMIT APPLICATION FORM SITE <br /> JAN i. 7 200 SAN JOAQUIN COUNTY MITIGATION <br /> NVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONMENT HEAW E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-344.9 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to Construct andlor install the work described This application 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 /> WELL Location 13d 56V Lv t 1�r+'�` Crass Street City 71p P�Assessors � �� v <br /> PROPERTY pp p p <br /> Owner AR q, Address �'1 r City aIOU4 Z.p g�F`hcn(ee�#,1/�a�^' 1��'1AP-s <br /> C.57 Contractor r ; Address �rJa CIty #f 1 Zip Y (BQ Lic# zo.+.,r,C..Phone# '313-58 <br /> Consultant/Sut7 Cntr Addie � r + ""CrtY *dAtA—I-i�t� ' �4�—Phone# 6' <br /> GIS Coordinates X Y ___ Township Range Section_ <br /> WORK TO BE PERFORMED <br /> +IEV11 WELL 1 BORING (CPT,GEOPROBE HYOROPUNCH HAND-AUGER,OTHER") V DESTRUCTION (choose type below) <br /> p SOIL BORING if p OVER-SORE= <br /> DIAMETER <br /> 'WFN L L# <br /> PRESSURE GROUT <br /> 'Other GROUT <br /> SPECIFICATIONS_ <br /> COMMENTS - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS !( <br /> J�NOFiING iOLLOW STEM DIA 01 E3pREHOLE�Q: Q MULTIPLE CASINGS I]MULTI-LEVEL WELL CASING DIAACTION AIR HAMMER/DRIVEN CASING THICKNES$�& _TYPE OF CASING 0 STEEL XPVC 0OTHER <br /> a VAPOR (]MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED AUGERS 0 HOSE <br /> p AIR SPARGII OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED Q Yes kl&o (NOTE. MArKIMUM FREE-FALL DEPTH IS 30') <br /> �]SOIL BORING HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER_a OTHER _ APPROX BORING DEPTH_a )WOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 60 _(rf YES,list specifications 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 this application and that the work will be done In accordance with San Joaquin <br /> County Ordi'aaRces u a tions,and all appheable California State Laws <br /> Signed x TitlelCompen � ��� �� <br /> Print Name .. Date ll( <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED <br /> Application Accepted fx'0A'' Date Issued ......... <br /> Grout Inspection By Date Final lnspect on By <br /> Date <br /> Oestructlan Inspection By Date <br /> MMENTS 1 CONDITIONS p /� ,�1//'� /� <br /> ACCOUNTING ONLY AID# FAC# �!� � V 0/4 57 7 7 <br /> PIs CODES FEE INFO AMOUNT REMITTED CHECK#86og RECD SY 15ATE PERMIT I SERVICE REQUEST# INVOICE <br />