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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />(209) 468-3449oo <br />pc NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 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 <br />'' Title, Chapter 9-1115.31I and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location <br />a�o5 tAvn,i"� cluCross Street City 11 p • Assessors <br />/ U�> Zip 1 Zv Parcel# <br />PROPERTY C�nS;dew4 1I ek5.1L9 't)addit55)//�� M� <br />Owner �i5 P� (� 5 Address --q-05- � j (o�1t'i� ✓�i City !vr, Zip �Phone# <br />C-57 Contractor_ n" SI r� Address_15Q�{ n_City nY Zip�/Y Lic# 654V7 Phone# <br />Consultant / Sub CntrS� v !;� Address 333o CAmfip�l ,/�i,CityWil�kn-y Phone#_��%_ <br />GIS Coordinates: X_ Y Township Range Section <br />WORK TO BE PERFORMED <br />ANEW WELL / BORING CP EOPROBE, HYDROPUNCH, HAND.AUGER, OTHER') <br />n SOIL BORING #- _t_0 <br />0 WEI L 4- <br />11 'Other <br />COMMENTS: -- <br />TYPE OF WELL <br />0 MONITORING <br />0 EXTRACTION <br />INSTALLATION TYPE_ <br />0 HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. <br />L PRESSURE GROUT <br />GROUT 'jpe.Gd : r1 <br />CONSTRUCTION SPECIFICATIONS <br />UTA. OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVELWELL CASING DIA: � <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER CL <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 01441' TREMIE TYPE TO BE USED: 0 AUGERS �OSE��p <br />0 AIR SPARGE/ OZONE'USH POINT (GP or CPI")GROUT SEAL PUMPED: `Yes 0� NTTo'' (NOTE: MAXIMUM FREE -FALL DEPTH I 30') <br />�OILBORING aHAND AUGER GROUT SPECIFICATIONS K/GitJb.t�!- (,4W ­jlo✓f' V' <br />0 OTHER:___ _ -0 OTHER____.___ _ _ ArrrzOX BORING DEPTH sG' 0 BOLTED TRAFFIC BOX or U SIJJE PIPE <br />COMMENTS: <br />CONDUCTOR CASING PROPOSED Au (if YES, list specifications in comment section) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PFRMITC <br />4tf 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 Ordin s e nd RjpaMtions, and all applicable California State Laws. <br />Signed <br />Print NE <br />L+L-1 F%I% I [n-1111 I V% 7G VIYL I <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />:5� <br />Gli1 <br />2. — <br />WORK PLAN DATED: - -'0,5 <br />_ <br />Application Accepted By <br />Date Issued <br />�C) <br />OGS <br />_ <br />Grout Inspection By_ <br />---- <br />_Date_. <br />_Final Inspection By <br />Area_ <br />� � <br />(6. r' -as <br />Destruction Inspection By <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE COD ESS FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY DATE <br />P RVICE T # INVOICE <br />i'520 22 147cso I 3f�� <br />� 1 131-16 <br />0 o b <br />l <br />