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06!07/2006 11:13 2044683433 EHD - PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY SITIGAT[ON <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209),468-3449 <br /> NON•REFUNC]ABLE PERMIT EXPIRES 1 YEAR FROM©ATE 15SU1=D JUN 5 2000 <br /> 0.pplieation is hereby made to San Jcaquin County for a permit to construct and/or install the work described. This aft f', a with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Heal �.f Ff <br /> WELL Locatian5-"t ` !Os VY i 5 I. � RM�Wf S <br /> �� Cross Street - City JM Zip Parcel# <br /> PROPERTY �• Evi <br /> Owner �' �� 1 Addr2ss �. �1 'SJClty Zip fOJr Phone#>' <br /> C-57 Contractor X100 to 1i &-Address i Ci "0 V/' ZIp7 l Lic#7�Phone#-70732 <br /> CansultantlSubCntr-izalwS Xld'ens? J C€� � 7582 <br /> h'„ - Lit# thsnf#_ <br /> GIS Coordinates;X Y 7ownsh€p Range Section <br /> WDRK TO 8E PERFORMED• <br /> Q NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER*) `,1KOESTRUCTION (choose type below) <br /> CIIAMETE0 SOIL BORING# _ 0 OVER-BORE, �149/^ <br /> 3) <br /> o WELL <br /> 'WRESSURi=GROUT <br /> 11"Other GROUT <br /> SPECIFICATIONS -"-' 61j!4 / � JJ ll <br /> COMMENTS; 3 V Gnr t "$c f ! Ute 0 tt>� 't1rglmilvecJf�' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> (MONITORING i1 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 11 MULTf-LEVEL WELL CASING 01AP <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:. a STEEL 1]PVC 0 OTHER: <br /> IMPOR <br /> 0 MUD ROTARY DEPTH OF GROLT SEAL SOI TREEMITYPE TO BE U-SEI7: O AUGERS p HOSE <br /> SPARGE1 OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED; X-Yes p No (tJOTE: [M M FREE- ALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HANE]AUGER GROUT SPECIFICATIONS J <br /> d OTHER: I1 OTHER APPROX,BORING DEPTH a BOLTED TRAFFIC BOX or Q STOVE PIPE . <br /> CON❑U TOR CASING PROP D (if YES,li t specilicatibns in comment section) <br /> COMMENTS: S— I rto lI( { !�' <br /> NOTE: FFSITE BOR! GS REQUIRE ACCESS AGREEMENT OR ENCROAC ENT PERMIT6. <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 Ordirialic R les and Regulations, and all applicable California d State Laws. r.I -7�.,�., <br /> Signed x Title/CompanU1y� .& t M I ,.__- <br /> Print Mame Date 5`,�p <br /> DEPARTMENT USE ONLY -- - <br /> SITE MAP IN UNIT IV FILE,ADDRESS: -2_0 ,e'0 <br /> WORK PLAN DATED: <br /> Application Accepted By i �v�.. •• Date Issued b 4 fo Area <br /> Grout Inspection By Date Final In!,pactlen-By <br /> Date _ <br /> Destruction Inspection-By Date <br /> COMMENTS/CONDITIONS: Cv5 e---r—o rr Pn y„v,jr $`L 53I <br /> OUNTING ONLY: AID# FAC# <br /> PE COot=S FEE lbiFO AMOUNT REMITTED CHECK# RECID BY DATE PERMITI SERVICF;PEOUEST# INVOICE <br />