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ORIGINAL <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 /> <br />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 Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location 15c)(Th lC 1. Cross Street gQ-,vroe,t+ City ala V-k-0/1 Zip q5d15 Parcel# 3 09-•._ <br />PROPERTY <br />Owner Ur' Ine;a1 &but e Wb ,V1kcidress QpcluD yo4.1.4(s.ryt 116. City Cleric zip,98:011 Phone# <br />C-57 Contractore CU C elCILQ Or .;-r•i5 Address AD 32 011ete.0 et rc1 L City (t).7T(i.tOt Zip 45/q;,7 Lic# 1115è Phone# 10 ri <br />Consultant / Sub Cntr rev foc+),,, aiwytWigrs ci TYlourrta City Lic# <br />TT <br />phone# 512 - cI90 — 19 ta-1 <br />'Dr eidoe . <br />GIS Coordinates: X 31 crlaky3t..) ,Y R?l. tiRs4. %dig , Township t111-1...i1 Range Section -r <br />WORKTO BE PERFORMED: <br />.NEW WELL! BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 13 DESTRUCTION (choose type below) <br />U SOIL BORING # S jr] OVER-BORE. DIAMt i LIR <br />VWELL# J-2p -Firvt,.„_31.-, fl V - 13 4 VE-3 44Irw-51-1 v e -S jj PRESSURE GROUT <br />D *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />*HOLLOW STEM DIA. OF BOREHOLE B" MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: 9" <br />0 EXTRACTION fl AIR HAMMIER/DRIVEN CASING THICKNESS 36.-+ . 90 TYPE OF CASING: B STEEL liPVC 0 OTHER: <br />VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALS-`1'- S.3 i 1E--L4RE-IMIE TYPE TO BE USED: c AUGERS HOSE <br />itAIR SPARGE/ OZONE 1:1 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: es 0 No (NOTE: MAXIMUM FREE-FALL DEPTEI IS 30') <br />CT SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS OelrYle_frk - \Cite )(1-tbin it-R- <br />n OTHER: 0 OTHER APPROX. BORING DEPTH RS-(120 1 Oft- VOkOLTED TRAFFIC BOX or El STOVE PIPE <br />CONDUCTOR CASING PROPOSED ki 6 (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 Ordina s, es and egulations, and all applicable California State Laws. <br />Signed x 71SC ca CfC Priaililtie/Company C aSC cf. de r-/' 1/i <br />Print Print Name e. I'..fi ryk_ t•-- Date r-o <br />DEPARTMENT USE ONLY <br />5icae.4) /611 - <br />Application Accepted By <br />Grout Inspection BY <br />Destruction Inspection By <br />DrTIONS. <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES - FEE INFO AMOUNT REMITTED CHECK 4 REC'D BY DATE PERMIT! SERVICE REQUEST ;`,E I 'VOICE <br />3*)11 MW g(t aa <br />ete04- / --.1 . SR# ee,b, is); Air <br />C-57 WC I-WAIVER <br /> <br />C-57 Letter of Authorization to sign permt nTrrraoc <br /> <br />TYPE OF WELL <br />MONITORING <br />SITE MAP IN UNIT IV FILE, ADD R.SS: <br />WORK PLAN DATED: i.q 0 <br />Date Date <br />Date <br />Date Issued <br />Final Inspection ate <br />Are. e <br />//1 4 a7)(ivv't//6