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WELL%RMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 <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 Developme Title,Chapter 9-111 .3 and the Standards of San Joaquin County Environmental Health Department. <br /> gbjo� ,p -tt� 1 ¢ Assessors t/ <br /> WELL Location Q &AQ Cross Street+-figb city Zip i5-5n 0No--Z / <br /> PROPER 1 1 1 SU-6 j) <br /> Owner 1e`! m,� �/a51 Address II3I LJ dr City \ Zip a7 Pho/Inee#�# <br /> C-57 Contractor rl li Address 4t„t Ci �19 Z PNJJ5J3 Lic E45 Phone#705-3r3-5sw <br /> Consultant/Sub Cnt6 'FAy, �0 Address '�'�Dr., 5vik 551D �,j(✓1 7J(a�'L <br /> iT" Cit hOWI Lic# Phone#5 0 �6"2d�Dz <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ` NEW WELL/BORING ( PT,PEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> OIL BORING# �,/j--4�j., -lfb,({1�� []OVER-BORE. <br /> DIAMETER ^IMMhT--T'�'T� <br /> 0 WELL# __ D PRESSURE GROUT <br /> a*Other _ GROUT <br /> SPECIFICATIONS __ - <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS no (W)1 wp <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE I 1 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS 'KO TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR XMUD ROTARY Qy't,J- DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 'AHOSE�//� <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED:1>1((Yes 0 o NOTE: MA IMUM FREE-FALL DEPTH IS 30' <br /> SOIL BORING D HAND AUGER GROUT SPECIFICATIONS =Z Cg ) <br /> 0 OTHER:___p OTHER APPROX.BORING DEPTH I2O/ _0 BOLTED TRAFFIC BOX or D STOVE PIPE <br /> COMMENTS: SPQ QL{ <br /> 1AI i (AcCO ND CTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> �+�QL <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 repared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi e R tions, and all applicable California State Laws. / <br /> Signed x Title/Compaoy_( L7 <br /> Print Name rl Date /D�Z�/0� <br /> DEPARTMENT US,El0NLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 25774- S-- P7f�n Az �Gl <br /> WORK PLAN DATED:�/ / / e P <br /> Application Accepted By_/ !!,VV 1�C o!L/,jOs7 Date Issued �I AV(w O S Area /Yf3 <br /> Grout Inspection By _Date Final Inspection By <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: yt <br /> ACCOUNTING ONLY: AID# FAC# S K o o i� 777 <br /> PE CODES FEE INFO AMOUNT REMITTED I CHECK# REC'D BY I DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3s0 l 89 Fs9£sY CH /d Vas <br />