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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 /> "ON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> it to construct and/or Install the work descn'bed. This <br /> Application Is hereby made to San Joaquin County for a permapp8cation is made in compliance with San <br /> ndards of San Joaquin County Environmental <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Staentai Health Department. Assessors <br /> WELL Location��I'r?5 9 d ,r {C�4�T�!'e Cross Street_ City Zip Assessors <br /> nl Zip Phone#cl//o-�i ' -32-30 <br /> PROPERTY OwnerTe c NlC�' rTL�r2EF_ r�C Address 3 R✓0 A S 70 y <br /> C-57 Contractor IJ Address a iso 4%?a M s 4✓e _City p -� <br /> c Phone# S 0 Sok <br /> Consultant I Sub Cntr <br /> Address CityLic#_ Phone# <br /> GIs Coordinates:'X7'�YEcs+ <br /> Y ,Township Range Section <br /> WohK TO E PERFO DESTRUCTION (choose type below) <br /> )KNEW WELL 1 ORING (CPT, EOPROBE HYDROPUNCH,HAND-AUGER,OTHER') Q Q OVER-BORE. <br /> OtL BO <br /> DIAMET �r G PRESSURE GROUT . <br /> Q WELL# GROUT SPECIFICATIONS G#f iPPcD <br /> Q*Other <br /> COMMENTS: e C� <br /> TYPE OF WELL INSTALLATION TYPE <br /> CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR KUASND <br /> D ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE!OZONEH POI (GP r CPT)GROUT SEAL PUMPED: Q Yes No ( OT : MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING AU GROUT SPECIFICATIONS <br /> OTHER: n OTHER APPROX.BORING DEPTH ? Q OLTED TRAFFIC BOX or Q STOVE PIPE <br /> ,�//���..� �J( / CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:��/'���Gt//l. �1/ <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.toaquin <br /> County Ordinance , R and Regulations, and all applicable California 6' ate Laws. _ <br /> Signe x Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> Q /V� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date issued <br /> Grout Inspection Area <br /> Date Finel Inspection By <br /> nsp By <br /> Destruction inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODESFEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br />