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WELAERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY SITE <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> 304 E. Weber, Third Floor, Stock UNIT 43 UNIT IV <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAFT�}tF1A" Sr��jam; tF`® i3 T Y <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the L <br /> Joaquin County Development Title,Chapter 9-11115.3 an the Standards of San Joaquin County Environmental Health Depart is made in Compliance <br /> with San <br /> WELL Location Shoup o Q � " ( ") �i <br /> 'T � a Cross Street �-j�1 (�C 27 Assessors ^`iJ <br /> PROPERTY SgY1 JDA vin r —"�--City r1Fq," jtrGL( Zip Parcel# 1/tWl <br /> Cov :yiicG/: ✓✓ <br /> Owner Address <br /> CC..••.. _City /�%+] Zip Phone# <br /> C-57 Contractor /•Ilfl _Address-M W( ` City/rIQ/'6jie2 Zi y Y994 <br /> 4�r /[ P Lic# Phone# ZrI <br /> Consultant/Sub Cntr 5 ti/zr ✓ Acoress��lylL"C U/ '1��City�4N�uy (' Ir95t k L _ <br /> -- ic# _Phone#57� /�v?Q/7G <br /> GIS Coordinates:X YTownship_ Range g <br /> WORK TO BE PERFORMED: Section <br /> NEW WELL/BORING 1(C�P ,GEOPROBE, HYDROPUNCH,HAND AUGER,OTHER') D DESTRUCTION (choose type below) <br /> OIL BORING#TY— <br /> DIAMETI R 5--'Intw ------ 0 OVER-BORE. <br /> D WELL# <br /> []*Other_ ____ <br /> ----------._._.__ .... D PRESSURE GROAT <br /> SPECIFICATIONS ----- GROUT <br /> COMMENTS: ---- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS FW C4i(i"A <br /> []MONITORING []HOLLOW STEM .10 <br /> DIA.OF BOREHOLE S'� D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 1V1" C TYPE OF CASING: 0 STEEL 0 PVC <br /> 0 VAPOR XMUD ROTARY4Ofr"9 D OTHER: <br /> JJ DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 9OSE/ <br /> D AIR SPARGE/OZONE 0 PUSH POINT(GP or CPI)GROUT SEAL PUMPED:'OYes �D��NAAo (NOTE:1J MAXIMUM FREE-FALL DEPTH IS 30')P�P <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONSg61L��.1Q/(.P�/1LL�NT ct jp;y� <br /> D OTHEP--------- —0 OTHER. _ APPROX. BORING DEPTH2S <br /> ---L51 0 BOLTED TRAFFIC BOX or D STOVE PIPE <br /> JJ COND C�TOR CAS7IN��G PROP SED ilk) _(if YES, list specifications in comment section) <br /> COMMENTS: lxt HtGn.! v1' G i. SO�ry {p JDiy Worj q 4i ✓ !'AhC G <br /> NOTE: OFFSITE SORINGS REQUIRE ACCESS AGREEMEN 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 Ordin a rd Rple-tioonns, and all applicable California State Laws. <br /> Signed x �! W�/ Title/Company�n Mw A& <br /> Print Name "1"�C! (./ _Date /f, <br /> DEPARTMENT USE ONLY —� <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 25775 $. P4.iJ2!vxYt f 45-S Ra( <br /> WORK PLAN DATED: <br /> Application Accepted By o(,C� Date Issued ay Q I <br /> Area <br /> Grout Inspection By — <br /> __Date _ Final Inspection By <br /> Date _ <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# _ FAC# SR `4ID '14/77G <br /> CPE CODES FEE INFO AMOUNT REMITTED CHECK# 89Jc( RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �`i w 89 ova i/b <br />