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i <br /> SITE MITIGATIONI ° IV FILE COPY <br /> WELL PERMIT APPLICATION FORMi <br /> SAN JOAQUIN COVN1Ty,,,:, <br /> ENVIRONMENTAL HEALTH � T (15 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> a (209) 468-34491 01=' fJ } QCt <br /> NON-REFt1NDA1LE PERMri EXI�IRES 1 Y 12 t#fOM DATE+tSSt3Et ., <br /> Perm <br /> to construct and/or install the work described. i hh"s aplkction is rnazle it#_Corjnpliance with San Joai <br /> Application is hereby made to San Joaquin County for a <br /> County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health De Athe'nt,;�,, j j c-) <br /> Assessors <br /> WELL L tion �' G rsLt�Gen,U;l ,`� t Cross Street �" 7 7 City ;;Te 'G;rcl1V Zip Parcel# <br /> PROPERTY Owner ce I,VAtxc x Address -?(d d11f.s 7l' gj City FL ,, ,J Zip ��S��f�'hone# � � �`�C? <br /> t,5 <br /> C-57 Contractor .�f..�� ��'�'�� '�~-- Address <br /> / G tf 1 > City �k79'?1�lf G Zlp`Jrf.2* Lich` Phone#f �t2s" s'i 'c <br /> Consultant/Sub Cntr ps�rL ldYt li i Address x i '--/ City Lich Phone# /G ��"� <br /> 77C ? f ' <br /> GIs Coordinates:X Y Township Range Section <br /> 1WO TO BE PERFORMED: } <br /> E 1®Le l RING CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHElts} ETR II T ISN {choose type below) <br /> BORING# Q C} ER-BORE. DIAMETER <br /> [�WELL# RESSURE GROUT <br /> n'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE"L rt LI MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 1]EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ®STEEL Q PVC 0 OTHER: <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL % � f C TREMIE TYPE TO BE USED: p AUGERS 0 HOSE <br /> a AIR SPARGE/OZONE j156SH POINT(GP or CPT)GROUT SEAL PUMPED: es ®No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30") <br /> OIL BORING nHRND RUDER GROUT SPECIFICATIONS <br /> a OTHER: n OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED_, C {if YES,list specifications in comment section} <br /> COMMENTS: �yT`7',�r'-�C:-�� , 7 l�"' <br /> NOTE: OFFSITE BORINGS REQUIRE AS E AGREE ENT EN R ASH ENT SER I T . <br /> 48 WORKING FOURS NOTICE REQUIRED FOR INSPECTION, <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Co <br /> Ordinances, Aches and Re ulati ns,and all applicable California State Laws. <br /> Signed x <br /> 2 t Idle/Company ! c✓4' ��'� �� C. r z <br /> me <br /> Print Na <br /> f ,c'' h Date % rte—r_ C7 f <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: � <br /> WORK PLAN GATED: <br /> Application Accepted By Date Issued 1 Area <br /> Grout Inspection By Date Final inspection By ate <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING OY�LY: AI FA <br /> PE CODES FEE WFO AMOUNT REM ECS CHECK# m fdEC'D 13Y [3A`r PE12C�lT 1 SERVICE F1L013EST#=INVOICE <br /> C-57_ W -WAIVE ____ C- Letter�f Authorization to sign er tt Encroachment doc 130r <br /> it <br />