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'1 WELL PERMIT A0IiPLICAT16N FORM SITE <br /> SAN JOAQUIN COUNTY �r-�j �� ; '�� <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EH - 1 +RATION <br /> 2007. 304 E. Weber, Third Floor, Stockton, CA:, 9520;AI;I � � UNIT IV <br /> i".'l•i': i'1 'HECR } (209} 468-3449 CC,,JJ t <br /> DEC.!, <br /> S'`f' T ;)V''E ENV1R{����fA;-fq HEALTH <br /> "�"� '4 I`" NON-REFUNDABLE PER XP{RES 1 YEAR FROM DAVE!SS <br /> Application is hereby made to San Joaquin County for a permit to construct andfor install the work described. Th s ��C:�f}ts�M1�tle�1 compliance with San <br /> Joaquin County Development Title,Chapter, and the Standards of San Joaquin County Environmental Health Department, <br /> WELL Location �4 r'rkr<. Assessors e <br /> { �� Cross Street I� City Zip Parcel# !3 i o i-,J <br /> PROPERTY f <br /> Owher��{ ( Address Ibll W, pu A „`City 5� n Zipq. I j;W-yhohe# <br /> C-57 Contractor Li.0j. Il;n Address $D h '4 City. 10 i Zipq 57 Lit# I�o7 Phone#7037-,37r/= fdD <br /> Consultant/sub Cntr Vi Addr ss �lr,m P� �}'r �C� qN� ��t��� phone#,�`1i76-�pZ <br /> GIS Coordinates:X 'Y Township Range, Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBI=,HYDROPUNCH,HAND-AUGER,bTHER*) >CDESTRUCTION (choose type below) <br /> D SOIL BORING# <br /> 6CVER-BORE. <br /> DIAMETER ) ^0-.2 <br /> Q*Other FILE COPY GRORESSURE GROUTI!'+ti(J <br /> -3)SPECIFICATIONS ll�+w <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE: CONSTRU TION SPEQFICATI NS <br /> a MONITORING fl HOLLOW STEM DIA.OF BOREHOLE 9 MULTIPLE CASINGS 13 MULTI-LEVEL WELL CASING DIA: <br /> J EXTRACTION (]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL U PVC 0 OTHER: <br /> a VAPOR `0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: .p AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL-PUMPED: 'Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING p HAND AUGER GROUT SPECIFICATIONS n6l <br /> l7 OTHER: 0 OTHER APPROX.BORING DEPTH a BOLTEDTRAFFIC BOX.or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment'sectlon) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> i <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. n <br /> Signed x Tftle/Companyf <br /> Print Name Date I +7 <br /> :DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: D YL free� <br /> WORK PLAN DATED: Q ' ' <br /> Application Accepted ay Irl Cr�e nater _ Date issued.- rJ ) a0 Area I <br /> Grout Inspection By Date) Final Inspection By 0 <br /> Date <br /> Destruction Inspection By s Date 2c"o 7 <br /> II <br /> .COMMENTS-/CONDITIONS: I^7 ` �� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE 8Y DATE -PERMIT I SERVICE REQUEST# INVOICE f <br /> 3562 GU.aU 6a,' 0)0 �C1"�' SRS U44 X13 4 S Ir <br />