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WELL PERMIT APPLICATION FORM __SITE <br /> VITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) SEP 2_i 2004 <br /> 304 E. Weber, Third Floor, Stockton, CA., 9520,`�i G`di���iV i Trj, <br /> (209) 468-3449PFRi';�111/5�=�?'•'I�'ES <br /> NON-RI=FUNPABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicationis hereby made to San Joaquin County for a permit to wnstruot andlor install the work described- Tbis app{ication is made in compliance with G San <br /> k <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San,}Paquin County Environmental Health Department�e�o�s t <br /> 300 JI C, City <br /> WELL Locatlon t S. 1��11+S �S{d ,_ Grohs$treeI ( ZiOt� <br /> t r Jon 2 S r .��- c x 3fi _Citi 5b C I C km ;;p Z� one; <br /> PROPERTY Owner �' r U l . }� <br /> city �C.K-�.,+�ZP��L;c# honeN <br /> Dt?z �idress_ ►�V,-�+- _��- <br /> C-57Contractor �ss <br /> re <br /> dd <br /> A <br /> Consultant I Sub Contractor lin <br /> 11.L 155 r Q✓ City_ ) Lic# Phoned 5 <br /> Range Szotian <br /> GIS Coordinates:X Y .Township <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> Q NEW WELL f BORING(Ge T,GEOPROBE,IIYDROTHER'}OPUNCH,HAND-AUGER. VER-BORE <br /> d SOIL BORING# []PRESSURE GROUT <br /> j] <br /> WELL Grout specifications= <br /> 'Other: Ort C4 Z. <br /> COMMENTS: C wz r luoY ( �w n ��ur <br /> CONSTRUCTION SPECIE(CATIONS <br /> TYPE OF WELL INSTALLATION TYPE '" pAULTIPLE CASINGS?j]YES ]0 WELL CASING DIA: <br /> OIA.OF BOREHOLE — <br /> gMONITORING jl HOLLOW STEM LPEOP CAS{NG: p STEEL '�6C D OTHER:_ <br /> OP D AIR HANINIERIORIVEN CASING THICKNESS r CAS(EMIE TYPE TO f3E USED: AUGERS 13 HOSE <br /> p VAPOR D MUD ROTARY DEPTH OF GROUT SEAL (o <br /> D AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Ye° Na (NOTE: MAXIMUM FREE-FALL DEPT <br /> IS 30'; <br /> ER GROUT SPECIFICATIONS:- , s <br /> STOVE PIPE <br /> D SOIL BORING D HAND AUGBORING, <br /> OTHER_---- APPROX-80RING BOLTED TRAFFIC BOX or DEPTH �� Dif YES,list;peGfi;,a[ions here) <br /> D OTHER:—U CONDUCTOR CASING PROPOSED"'. <br /> 'COMMENTS: <br /> NATE: OFFSITE BORINGS REQUIRE ACCESS OENCROACHMENT LREQUIRED INSPECTIONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE <br /> hereby certify that l have prepared this a plication and that the work will be done in accordance with San Joaquin <br /> Countyrd antes,R s a d Regulati s,and all applicable aiiforni �oteOLaws. 2 <br /> Titie)Company it <br /> /A <br /> Signed x , Date <br /> P ' Cj C, <br /> PrintNamO DEPARTMENT USE ONLY. <br /> SITE MAP IN UNIT IV FILO,ADDRESS: <br /> 1NORFt PLAN DATED: VV / ZO� <br /> Date issued a <br /> Application Accepted By Date Final lnspectlon BY <br /> Date, <br /> Grout Inspection By Date / <br /> Oestruction Inspection By — <br /> COMMENTS I CONDrrIONS: <br /> ACCOUNTING ONLY: .AID# <br /> c e r—te <br /> CH>=CK# RECD DATE PERM>Tf S <br /> ERVICE REQUEST SF INVOICE <br /> pE CODES FEE INFO AMOUNT REMITTED 2� size `' 3 <br /> qoz 0 , 00 1 g q�4 1/25, <br /> G-57 WC -WAIVER. C--57 Letter- of Author n o sign permit Encraachfnent dot __ <br />