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a {"� <br /> g V WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicatton Is hereby made to San Joaquin County for a permtt to construct andlor Install the work described This application is made in oompliance with San <br /> Joaquin County Development Title,Chapter 9-1115 3 anq the Standards of San Joaquin County Environmental Health Department <br /> �� Assessors <br /> WELL Location ST �"' Cross Street +leLi Sr City 5 ,T.ip <br /> PROPERTY Owner6l��/T fJf-7� address N E lh da �r Cdy SM--kjw Zipi3RDLPhone • 37'86 <br /> j �yfl�jz C� y�7Phone# x -600 ContractorLX=W j--A aft1& Address�Si9 f{riW C /Zd� --City M2 P <br /> Consultant/Sub CntrCdtlll!br i Fri• Address a7D i4� City �u Phone#)�7-J 33'a� <br /> GIS Coordinates X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED- <br /> NEW WELL/BORING CPTGEOPR)BE,HYOROPUNCH,HAND-AUGER,OTHER-) d DESTRUCTION (choose type below) <br /> gSOIL BORING# ^17 S - 8 []OVER-BORE DIAMETE <br /> d W ELL# PRESSURE GROUT <br /> 'OtherGROUT SPECIFICATIONS <br /> COMMENTS o r1 1c��Wa1 de e� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING HOLLOW STEM DIA OF BOREHOLE-L— aMULTIPLE CASINGS a MULTI LEVEL WELL CASING DIA ^+-04 <br /> Ii EXTRACTION j]AIR HAMMER/DRIVEN CASING THICKNESS--ALA—TYPE OF CASING []STEEL U PVC [)OTHER <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL_(Do r TREMIE TYPE TO BE USED (]AUm$N dsk <br /> AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED )(Yes (I No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING D HAND AUGER GROUT SPECIFICATIONS µ <br /> I]OTHER-- n OTHER APPROX BORING DEPTH—&9L---- —[1 BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED--10--!P— YES,list specrfications in comment section) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <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 nan les egulatlons,and all applicable California State Laws <br /> Signed x <br /> TitlelCompany 1,1�i � <br /> Print Nama_� Y15 r . �DEPARTMENT USE ONLY Date <br /> SITE MAP IN UNIT IV FILE,ADDRESS: oZ �' �� I L� <br /> WORK PLAN DATED: b~ 5-02 Z0-O"L- <br /> Application Awapted By <br /> Date Issued & <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> [ACCOUNTING ONLY AID# FAC# <br /> ODES FEE INFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT1 SERVICE REQUEST# INVOICE5of /S��- 10.7 SR# 490 870 <br /> C-57 WC -WAIVER C-57 Letter o�uthorizatlon o sign permit ✓Enc � ldoc 9/30/0 <br />