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NOO-04-2003 17:19 CAMBRIA <br />1707 ,33` R I GWA L <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />Fl A i A/li/ <br />&QN-REFUNDABLE PERIII(IT EXPIRES 1 YEAR -FROM (]ATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or 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 6{ �t-�.-.-�� Cross Street 11L,4 :s4.// // Assessors <br />City 57c�k Zip_`7„�,Parcel## <br />PROPER `/ <br />Owner 5 % O; ��Ys 4s dress p. n. 8�>C ( City. t�`ij�< Zip`r1$/C� Phone# <br />C-57 Contractor ��-;��;^ £- Address9_so RaracQ City/"�+r �t�ezZi 7 53 LiC#` Sl6SPhonpfi��zj- -�$oo <br />Consultant / Sub Cnt .-+ u��. �� ddress�rK City^Liq#�C; _ Phone!# `la3- 2l <br />GIS Coordinates: X Y Township Range Section <br />WORK TOBE PERFORMED: <br />NEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) it DESTRUCTION (choose type Mow) <br />if SOIL BORING # - OVER -BORE. DIAMETER <br />,'a WELL #_s- s�_ _ z _ gg a[I PRESSURE GROUT S <br />L] Other GROUT SPECIFICATION5 <br />COMMENTS: <br />TYPE OF WELL !t45TALL&nQN INSTRUCTION SPECIFICATIONS <br />� <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE ��� q <br />�_ � MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: L/ <br />11 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESSs<- `ice TYPE OF CASING: p STEEL <br />U VAPOR (] MUD ROTARY )(PVC � OTHER: � <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS )V -LOSE <br />Q AIR SPARGE! OZONE )(PUSH POINT (GP or CPT)GROUT SEAL PUMPED: OYes a No (NOTE: MAXIMUM RFE-FALL DEPTH IS 30') <br />ASOiL BOR1N(� V_r) a HAND AUGER GROUT SPECIFICATIONS Par ---i 1q-CZr-)�~/� <br />p OTHER:_ It OTHER APPROX. BORING DEPTH Z-- 96' t-260 OLTED TRAFFIC BOX or p STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications In comment section) <br />COMMENTS; Z,�R GS ((o� g61 t _ GP7 <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 tha wnrlr will rhe fi^-- c.. -.___-____ <br />Counf <br />Signed <br />Print Ne <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: .l_,_,Le , <br />Application Accepted <br />Grout Inspection By_ <br />03 <br />6cr4�-� <br />TOTAL P.02 <br />