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3 T APPLlCAT10N FCM SITE <br /> WELERM1 MITIGATION <br /> SAN .IOAQLIIN 'COUNTY EHD V <br /> ROFaVED ONME1`1TAL HEALTH ------------ <br /> Third <br /> D UNIT I <br /> ENVIR <br /> E4 1 5 � 3Q4 E Weber;Third Floor, 3449 -on;.0 , <br /> S -(209) 468-3449 . <br /> PRINT HEALTH �' -. liance with San <br /> MAT ICRR C Iication is made iri comp <br /> IT N REFUNDAB to PERMIT kuct andlorEnstall he work descchbed. ThiDATE s PP <br /> PERM lor'ayperm Assessors <br /> Application is hereby made to San Joaquin County theian � of San}oaquin County Environmental Health Department. <br /> Joaquin County Development Title,Chapter 5 i 1115.3 and; r� }, zip _�ParCe4# <br /> i 1, 1 -U4. ` Cross treet d/ S,r� City <br /> W pa <br /> WELL Location r fGrl ��OJfo� <br /> IJd62- Phone# <br /> 5 I , Zip r <br /> PROPERTy� �s.�.. � t4f� PJ�_Ci� �013 s <br /> k Owner `t o Address. „ s G4 9000 Sia—9a3=mss <br /> rjq��{ r� "`i 1 Lic#. Phone# I <br /> 1�3V4q F,Florc.�� A„t,� city P zip <br /> i C-57 Contractor aSC�ernce Addres 3330 D� ~l'i�i S o ��� �(A(,QyZ Phone# rXJ"{0/ � <br /> �y9�iJ5 � V�•'�•t1Address J City i <br /> Consultant/Sub Cn Section <br /> r Township Range <br /> GIS Coordinates:X Y <br /> I WORK TO BE PERFORMED: ❑E$TRUCTIOM (choose type below) <br /> NEW WELL 1 BORING�,i.C..PT.GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER') 0 OVER-BORE. <br /> SOIL BO RING# LJ' 1�� <br /> DIAMET l '' 0 PRESSURE GROUT <br /> 0 WEtL GROUT <br /> 0'Other <br /> SPECIFICATIONS - Jim <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ! Q MONITORING 0 HOLLOW STEM DIA.:OF BOREHOLE_? 0 MULTIPLE CASINGS ©MULTI-LEVEL WELL CASING OiA: t <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS tTYPE OF CASING a STEEL 0 PVC a OTHER: A- <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL # 0' TREMIE TYPE TO BE USED: B AUGERS HOSE <br /> 0 AIR SPARGF/OZONE ,>*USH POINT(GP or CPT)GROUT SEAL PUMPED: 5- ` rr ,' : MAXIMUM FREE-FALL DEPTH IS'30'). <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIO E✓1! {�iYrlJtilti o m <br /> 4 0 OTHER: 0 OTHER APPROX. BORING DEPTH 11 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> (CON UCTOR CA$l PROPOSED {if YES, list spec i ications in comment.section) <br /> COMMENTS: 'BVI[. C311Ir !U <br /> NOTE: OFFSITE <br /> BORING -I'M= ACCESS'AGR EME TOR ENCROACHMENT E ITS. <br /> i, 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 Ord in es, I s d R ulat' s, and all applicable Cali.forniaaState Laws. <br /> �� _ <br /> Signed x + TitlelCompany t� 1 t 1t 6 �O <br /> { Print Name 6e rat P <br /> Date <br /> DEPARTMENT USE ONLY <br /> ` SITE MAP IN UNIT IV FILE, ADDRESS: C) 3 ST <br /> WORK PLAN DATED: p <br /> '. Application Accepted,By. j� Date Issued �dG Area ( / 7 <br /> i Grout Inspection By $1A Date Final Inspection By <br /> Date - <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> C <br /> ACCOUNTING ONLY: AID# ,FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> } 0z-—3 fJ lC 91z °` s,e oo a U+ <br />