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WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY TION <br />( <br />ENVIRONMENTAL HEALTH DEPARTMENT EH <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 DEL <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU99VIR0NN`1t.�I�'T 1'f <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This a ry ic�,m fiance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Heal h�rfikt�I� <br />Assessors <br />WELL Location �� '[/ rJ UT r� 5 T( -Cd Cross Street W Z A ewkcity �1 `� Zip C� 5[,� �7 Parcel# 1 5 3 -• 190- U <br />PROPERTY <br />Owner <br />. t j ddress I� .ff 1 500 Z CityJ(t(jzl rnk Zip 58 <br />5Phoe# <br />C-57 Contractor C/«A066 IM Address 30-"1-( EFk/' C6Citv ip �4ic#/12013 <br />Phone j 6 ' 1300r5 <br />Consultant/ Sub Cntr irl") GyV�AwUvll Address 3-5-t6awrW, pr, cly( KWOLc'A 'Phone# '50-"(7&- Z <br />bZK <br />GIS Coordinates: <br />Y , Townshi <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 SOIL �ING # (J - No CPT—'71 <br />DIAMETER r M t <br />0 W LL # <br />0*Other <br />SPECIFICATIONS <br />COMMENTS: <br />Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. <br />XRESSURE GRO T <br />GROUT 136107t/j' H011,14 500�) <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING [] HOLLOW STEM DIA. OF BOREHOLE �0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS �1 r6' TYPE OF CASING: 0 STEEL [] PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL) :- ISO TREMIE TYPE TO BE USED: 0 AUGERS )(HOSE <br />[] AIR SPARGE/ OZONE VUSH POINT (GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOTE' MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS teivi &4 5&/ EUO <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH S5 -15�> 0 BOLTED TRAFFIC 40X or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED Al�% (if 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 Ordirlances, Rules and Regul4t(pns, and all applicable California State Laws. <br />Signed <br />Print <br />SITE MAP IN UNIT IV FILE, AJDDR <br />WORK PLAN DATED: `I _I <br />55: <br />5 <br />DEPARTMENT USE ONLY <br />Application Accepted B Date Issued 12_17_7_ 1i1 Area / 9 <br />Grout Inspection Bye_ f Date Final Inspection By <br />Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />rCHECK# <br />REC'D BY <br />DATE <br />P ERVICE REQUEST # <br />INVOICE <br />S.�0o��3oz <br />