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WEL 'ERMIT APPLICATION FWRM SITE <br /> SAN`JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, GA., 95202 <br /> x(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 andlor install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9.1 115.3 and the Standards of San Joaquin County Environmental Health DepartmenAssessors j _ '��T <br /> 107 (1ip/\�1 c (, (,,� [}, Zi I�ZS Parcel# 1 U <br /> WELL Location tJ,� 11/ d� c7�f� Cross Street lN�w 11'� City V�+� � P <br /> PROP TY f 'f Q 5 khone# <br /> Owner (. �u CO <br /> AddressROAM'7t�C 6wz _City {f ZiP. <br /> C-57 Contracto C 6Qo%.&y(� Address �.� <br /> r�nc� .i4vt. 5 ity`�R '°""ys .zip qD 67A_ic#.74aoi3 Phone# Sl _9v X053 <br /> # SSo Cavn�L G4 95�Phone#5 7� � <br /> j; �{ .> 3i7 CaiNiorr� [)!: y <br /> Consultant!Sub CntJ�<� nt AddressCt <br /> GIS Coordinates:X <br /> y,,Township Range Section <br /> t <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type-below) <br /> �IEW WELL I BORING (CPT',GEOPROBE,HYDROPUNCK HAND-AUGER,OTHER`) [] Q OVER-BORE. <br /> SOI 0RING# <br /> D[AM ETE [] PRESSURE GROUT <br /> []W GROUT <br /> []*Other <br /> -SPECIFICATIONS <br /> COMMENTS: <br /> S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />+ [] MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE lar tt []MULTIPLE CASINGS [] MULTI-LEVEL WEi_L.CAS4NG DIA: <br /> l <br /> {: <br /> [] EXTRACTION []'AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: []STEEL GPVC []OTHER: <br /> Q VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL I3v TREMIE TYPE TO BE USED: ©AUGERS Ji•#OSE <br /> 'D AIR SPARGE!OZONE_ USH POINT(GP or'CPT)GROUT SEAL PUMPED: N TE: MAXIMUM FR E-BALL pEPTH IS 30') <br /> 'r [] SOIL BORING i]HAND AUGER GROUT SPECIFICATIO S �✓ +'� . <br /> [] OTH R: q OTHER 'APPROX. BORING DEPT I []BOLTED TRAFFIC BOX or' a STOVE PIPE <br /> CONDUCTOR CAST ,G PR POSEDr � (if YES,list specifications in comment section) <br /> t CommENTS: �' �[5 Wr e !I �{}��f�f r iN1.... "` !0 ri�i f21VyIL�W4& `:?A <br /> NOTE: OFFSITE BORINGS RtQUIRE ACCESS AGREEMENT OR ENCOZOACHMENT P RMITS. <br /> I <br /> 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=ces, es andz;r� <br /> and all applicable California State Laws. <br /> Signed Title/Company eI�'1 ofro �'KD 2� ��/• WvE <br /> Print Mame ''V� Date <br /> DEPARTMENT-USE ONLY . <br /> SITE MAP IN UNIT IV FILE, ADDRES : 3 <br /> WORK PLAN DATED! <br /> Application Accepted By Date-Issued -1 I'll O 62 Area 79-7 <br /> Grout Inspection By a7 Date Final Inspection By <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> II ACCOUNTING ONLY: AID# <br /> FAC# <br /> [ PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# 1;1iVOICE <br /> 102 <br />