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WELL PERMIT APPLICATION F• --- <br /> SAN JOAQUIN COUNTY M SITE <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> 304 E. Weber, Third Floor, StockUNIT IV <br /> (209) 468-3449 dC t'05W I' 43 <br /> Application is hereby made to San Joaquin Co ty or a pee-rm6 to ctLE - 1 t EXPIRE 1 Ythe 1 J` ` ,J I f COUNT Y <br /> Joaquin County Development Title,Chapter 9-1115.3 an the Standards of San Joaquin County Environmental Health Department. <br /> �" � qeT" 4 PTOR IWIlcAf'Pn is made in compliance with San <br /> WELL Location tiQU� /- P Assessors <br /> CC� -L- Cross Street <br /> _City 4pq/. �Zi 1� 3 <br /> PROPER -411 OQ vin (bv 1) is weik P 3 Parcel# <br /> Owner Address_ <br /> ` ___City Zip Phone# <br /> C-57 Contractor •Q full —Address _City bfez Zipq(/ � YO�kJ <br /> Consultant/Sub Cntr ,5 yfy �' 71?� hfl �-G$Lic#Y� Phone# Z$3/3-�vc� <br /> Addres _ l.� fKLic# Phone#530-/0*206Z <br /> GIS Coordinates:X <br /> --'Y----_.__-_.Township Range— <br /> WORK TO BE PERFORMED: — Section <br /> NEW WELL/BORING ( PJ,GEOPROSE,HYDROPUNCH, HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> OIL BORING#�- ,___ <br /> DIAMET <br /> 0 WELL# OVER-BORE. <br /> 9*Other_ `— --- -- 0 PRESSURE GROUT <br /> SPECIFICATIONS ---- GROUT <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE <br /> U MONITORING �— CONSTRUCTION SPECIFICATIONS � Cyp'Iric/0 <br /> 0 HOLLOW STEM DIA.OF BOREHOLES,, �,,,0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> n EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS rL r4 <br /> 0 VAPOR XMUD ROTARYCOfM9 DEPTH OF GROUT SEAL TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPI)GROUT SEAL PUMPED: Yes TREMIE TYPE TO BE USED: GAUGERS OSE�� <br /> OIL BORING 0 HAND AUGER ,, __ ++0_N'o (NOTE:/MAXIMUM FREE-FALL DEPTH IS 30') <br /> GROUT SPECIFICATIONS_KQi(Q/(yy�.yJf c/0-4 <br /> ()OTHEP•__—__0 OTHER ,_ AppROX.BORING DEPTH �2� <br /> —10___, 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �ORIN <br /> CON p TOR CASING PROP SED 140 (if YES,list specifications in comment section) <br /> COMMENTS: Ctt „y, I. S�„ '�t,� n�o)iIq Sgyt 7pnoci v44,. <br /> NOTE: OFFSITE S REQUIRE ACCESS AGREEMEN OR ENC OACHM NT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin d R tions, and all applicable California State Laws. <br /> Signed x_ <br /> � ___Title/Company ��•1�/� ®�¢/��- <br /> Print Name (/fI <br /> DEPARTMENT USE ONLY —Date�� � <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ZS77$ $. Paiter , 'P4.TSj�0( <br /> WORK PLAN DATED: <br /> Application Accepted By /t// �.sl�t/1o'l V Anil Q T Area / .3 <br /> Grout Inspection B Date Issued_ �L�� <br /> _Uate Final Inspection By <br /> Date _ <br /> Destruction Inspection By <br /> Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# SA' 4rooaly774 _ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 89dY RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> IP F9 <br /> NG <br /> /1,0,0 65' <br />