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WELL PERMIT APPUCATION FORM , IT-F <br /> - WtIGATION <br /> SAN JOAQUIN COUNTY SEi'' ��TLUO <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 EvVIROKIII ,1[ i <br /> (209) 468-3449 PERPii!T/SE11iVjr'EC, <br /> ?lON•REFUNAABLEpERMIT EMPIRES I YEAR FI20M DAT> tSSUis>=D <br /> Application is hereby made to San Joaquin County for a permit to Construct andlor instant Chu ry En ironment3l Heath Departm nt plication is e in cornplianCe with San <br /> Joaquin County Development Title,Chaplet 9-1115.3 and the Standards of SalntJoaq � Asse55o�s <br /> 4a1 1 Ci ' p_ parcel#_ <br /> WELL Locatlon'J`�51 S, his 9 �� Crass Street E City // <br /> y� Address �{ L f 5mg11 � city �� r1-�eCa zlpbPhonen zt �rilc�i'zi <br /> PROPERTY Owner oll 6i�Y <br /> �T�✓e- ci S ''� zPq�i?_c��Li���t�L�'`�'Phone;��Qq-�fb5-2��tZ <br /> c-s7contractor5 cfru <br /> ICC lu Udress_4� <br /> Ay Ci �� +�`c''l_i k Phone#5t C, -SI 1 <br /> ConsultantfSub ContractorC1� 1 ( <br /> Address I'd� � i 5lp--t5b1-1-b"z� <br /> Y -Township <br /> Range Sect on <br /> GIS Coordinates: <br /> WORK TO 8E PERFORMED: )(DESTRUCTION(choose type below) <br /> 13 NEW WELL BORING(CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,DTHER ) /T 'OVER-BORE <br /> U SOIL GORING* - + p PR <br /> ESSURc GROUT <br /> DWELL# C,routSp?cifica6ons'_ ' �r+l <br /> •Other: lip tO '„1 Gtr 92 <br /> COMAS: F{; ,,- /A. <br /> L CONSTRUCTION SPECIFICATIONS <br /> TYPE OF WELL_ INSTALCATION TYPE — :-- NO WELL.CASING DIA <br /> pN174RING R HOLLOW STEM OIA OF BOREHOLE IZ io MULTIPLE CASINGS?Q YES <br /> ® gM TYPE OF CAST !G: 11 STEEL �'VC 0 OTHER: <br /> g'FXTRACTION 0AIRHAN14tERlORIVEN CA5INGTHICKNESS <br /> Q VAPOR Il MUD ROTARY <br /> DEPTH OF GROU'i'ScAE ?'U ��{'} 7REMI1=TYPE TO BE USED- AUGERS urHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED-. yes a {NOT IMUM ARE 'FALL DEPTN IS 30'; <br /> HAND AUGcR GROUT SPECIFICATIONS: *tel <br /> j]SOIL BOR]NG I) OLTEO TRAFFIC BOX <br /> or STOVE PIPE <br /> 0 OTHER:��11 OTHER �1 APPROX.BORING DEPTH 3D 1 <br /> CONOUCTOR CASING PROP OSEC)-.,OPOSED? (if Y> S,list spec ficat ons here): <br /> •COMMENTS: L-)v O r% NT PEMI this <br /> NOTE' OFFSITE 13ORINGS REQUIRE C5S v4N E FOR ALLHME <br /> RD ENS ECTIONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN A� <br /> hereby certify that l have prepared this application and that the work will.be done in accordance with San Joaquin <br /> y le and Requl Ions,and all applicable California State Laws. (2AA 24A RILL <br /> LL <br /> County rd' antes,fait ��++ �,}h _ TT <br /> (�) Ti>je1Campany C: <br /> Signed x 1 }} Date ` <br /> Print Name O Q 1' ` Luc i <br /> DEPARTMENT USE ONLY. 6' 7J— FJ 0 �/y ✓ <br /> SITE MAP IN UNIT IV FILO,ADDRESS: <br /> WORK PLAN DATED' Z� Zvi <br /> C _ Date Issued a <br /> • c,. >` � <br /> Application Accepted By Date Final Inspectlon ByDarn <br /> _ �__� <br /> Grout Inspection ey Date (, <br /> 06structionlnspect n_ �� 2 f�` J ((SSS 'C <br /> �� - �-� <br /> COMMENTS lCOND IONS S kv, � �(hs �� <br /> 1r40 <br /> accou"Nc 0”- AIO# � <br /> PE CODES FEE INFO Ah1QUNT REMITTED CHECK# RE 'D Y DATE PERMrr!SERVICE REQUEST# INVOICE <br /> �o Z <br /> 1 23 o SRe I 1/25 <br /> C�57 E-etter of Auth rizat' n�o sign permit Encroachment dot <br /> G_57 WGA WAIVER <br />