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APPLICATION FORM ----------- <br /> WELL PERMIT <br /> SAN JOAQUIN-COU.COUNTY FL�)." $ITE <br /> ENVIRONMENTAL HEALTH DEPARTMENT 40ATION <br /> -2007 304 E. Weber, E[i UNIT IV <br /> Third Floor, Stockton, 9520�4t, <br /> (209) 468-3449 <br /> MES <br /> Application is hereby made Id San j NQU-RXFLIND�41LE ENV ONMEN HEALTH <br /> 'NV <br /> quin County for a permit 10 Construct andfor Ins S <br /> JI tho work descrlb'M <br /> Joaquin County Development TIlle,Chapter 9-1115.3 and the Standards of San Joaquin Coumy led.I Compliance with San <br /> WELL LocMlon- I C­ .- cl*' tv eer�4. Avc Environmental Health Department, <br /> CrossStreet CI <br /> 5bgk�zip-i5ozo Ap-a-rc,:­-E 3 <br /> PROPERTY <br /> Owner Address <br /> C-57 Contractc)r ty ZiP-Y5R*hon,t <br /> Add,.. 550 <br /> _ZLOD7 Phone# <br /> Consultant/Sub Crjtr2fd-1�1/1' -&Iz Phona# <br /> GiS Coordinates:X 'y Township—Range <br /> Section <br /> WORK TO BE pEaEgBMM. <br /> 3 NEW WELL I BORING (CPT,GE=-Oj-3R­0-BE,HYDROPUNCH.HAND-AUGER,OTHER*) <br /> 0 SOIL BORING# DESTRUCTION (rhWse type below) <br /> DiAMETFIR XOEVER-13ORE.. <br /> 0 WELL# <br /> D*Oth&r - N RESSURE GROUT(54W <br /> SPECIFICATIONS _ <br /> GRO9 <br /> COMMENTS: <br /> TYPE_ OF WELL INOTA-1.1-ATION Typrn CONa'rRucnQN SPECIFICATIONS <br /> 0 MONITORING D HOLLOW STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAM.MER1DRIVEN CASING THICKNESS_.TYPE OF CASING: a STEEL 0 PVC 0 OTHER: <br /> a AIR SPARGE)OZONE -�HOSE <br /> 0 VAPOR a MUD:ROTARY DEPTH GROUT SEAL TREMIE TYPE TO BE USED: EIAUGERS <br /> 0 PUSH POINT.(GP or CPT)GROUT SEAL PUMPED: �es a No (NOTE: MAXIMUM FRSE-FALL.DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIF=TIONsnaii cf�ij <br /> :0 OTHER:— —0 OTHER— APPROX.BORING DEPTH. <br /> 1]BOLTED TRAFFIC 80X or 11 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED , <br /> COMMENTS: (If YES,list SPOCif4call0tis In Comment section) <br /> NOTE: OF SITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED.FOR INSPECTIONS. <br /> f hereby certify that I have prepared this apiplicatlan and that the work will be done In accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all-applicable-California State Laws. <br /> $Igned x <br /> Print Name7Itielcomparly I^c;&i C,- <fr, <br /> -Date E�PA <br /> �TUSE USE <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED'_ <br /> Application Accepted 8 <br /> - - 82ta Issued- jlntJe3j� 1?, .2-007 Area <br /> Grout Inspection B -Oat Fina?Inspection By <br /> Date <br /> Destruction InspectiLn By Date <br /> 'COMMENTS/CONDITIONS: kmr,n 4-hi� <br /> ACCOUNTING ONLY: AID#' <br /> FAC# <br /> PS CODES FEE INFO AMOUNT REMITTED CHECK# REC"D BY DATE PERMIT I SERVICE REQUEST# INVOKE <br /> 350z VLO-00 ca,oo <br /> SRS 004 9 3 48 <br /> a <br /> li <br />