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WELLPERMIT APPLICATION F• SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockf,�.Ey5f? I: 43 <br /> (209) 468-3449 <br /> IID A�T Y <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAIT Jk£ S8H <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the1'94�IA4eT0tBt.pTPip qp&Ipn is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-11115.3 an the Standards of San Joaquin County Environmental Health Departm�etnt. [ <br /> WELL Location hOu� yitA c W1� Cross Street Ci 11Pq/' qs3 1 Assessors <br /> C�5 ( ty 141j Zip Parcel#_ _ l <br /> PROPERTY J0.h OQ vin Cbv vbhe k191b <br /> Owner Address City I Zip Pho�n�ep# �t <br /> C-57 Contractor G /11(IK _Address I,fI( (�, /y�II�� City Yn //ZipLic#YD9l4J phone#2 <br /> Consultant/Sub Cntr .5 V(s �V'Addressa6j4g 11/7\ V/�T it)(4Yru1tV1 Al QST z Phone#530 V7��<76z <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORINGn (�P�,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') O DESTRUCTION (choose type below) <br /> 'MOIL BORING#�-`f_ _ _ a OVER-BORE. <br /> DIAMETL'R_ ' S-'j j a <br /> a <br /> a WELL# d PRESSURE GROUT <br /> 0*Other . GROUT <br /> SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Oto C41--yo <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE S}��.,,,,a MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS !W��-'C TYPE OF CASING: 0 STEEL a PVC a OTHER: <br /> a VAPOR XMUD ROTARY�ot; 1 DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS *OSE P� <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP orJJCP1)GROUT SEAL PUMPED: $Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING Q HAND AUGER GROUT SPECIFICATIONS];!h O - <br /> 1]OTHEP•____ 0 OTHER____v_,__.__,.,_ APPROX.BORING DEPTH 135 H BOLTED TRAFFIC BOX or U STOVE PIPE <br /> J CO��jD� TOR CASING PROP SED PW (if YES,list specifications in comment section) <br /> COMMENTS: f l(La rj II 5—+��'IYIU.UA7 iD� nk/001 5441 � 4 biyJ� TOAli'r (/ALJ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMEN OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin d R ions, and all applicable California State Laws. <br /> �s�t-eA /j� <br /> Signed x_ KEWv Title/Company 6W /Q� �/jQ �.,, �r1SWIP <br /> Print Name �//irK N _Date le ,Zilqr <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 2-.5 S• RLVkrrx" 'Pcs-S Ro( <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued /a av Q Area <br /> Grout Inspection By _Date Final Inspection By <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: ® / <br /> ACCOUNTING ONLY: AID# FAC# SalO� �y 77V <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#8Mid RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ��w V9 <br />