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WELL'-OERMIT APPLICATION FNM <br /> e: <br /> - SAN JOAQUIN COUNTY SITE <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> 304 E. Weber, Third Floor, Stockton, CA., 9:5202 UNIT IV <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERM€T EXPIRES 1 YEAR FROMDATE ISSUED <br /> Appfcafion is hereby made to Sen Joaquin County Tor a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location aSp D 1 eye Ll Ay.,, Crass Street 6M Sa t�City �,� Assessors <br /> yurwtif/ Zip��Parcel <br /> PROPERTYA T fZac� <br /> Owner A f IppP4, Address�DD rr <br /> !!���� E �10. <br /> 4E overt t, CitG57 Contractor �(1p4 ��i�fiAddress lit <br /> �p ;,,c t City ,c� [!; <br /> < 1 ZjP?g5.LLic#_110�Phone# <br /> Consultant/Sub CntrJ r SIjV�ror� Addres '-�1550 c�t4a+a <br /> �3� �Yr1� Pa��, City � Lic� <br /> GIS Coordinates:X 'y Townshi <br /> P Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL 1 BORING CPT, EOPROBE, HYDROPUNCH, HAND-AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br /> SOIL B R NG# - <br /> DIAMETER []OVER-BORE. <br /> 0 WELL# <br /> []*Other Q PRESSURE GROUT <br /> SPECIFICATIONS GROUT <br /> COMMENTS: �; S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING "K,OLLOW STEM DIA.OF BCREHOLE {I ]]MULTIPLE CASINGS D MULTI-LEVEL WELL CASfNG DIA: <br /> []EXTRACTION 0 AIR HAMMER/DRIVEN CASING TH#CKNESS TYPE OF CASING: 0 STEEL 0 PVC aOTHER: <br /> []VAPOR 0MUD ROTARY DEPTH OF GROUT SEAL 'F4 �- OF TREMIE TYPE TO BE USED: []AUGERS KHOSE <br /> []AIR SPARGE/OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPED:XYes p 0 No (NOTE: M IMUM FREE-FALL DEPTH 1S 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIPICATIONS <br /> []OTHI=R: 0 OTHER APPROX. BORING DEPTH I U [] BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED—M (if YES,list specifications 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 Ordinances, Rules and le ulations, and all applicable California State Laws. <br /> Signed x TitielCampany [ i ` <br /> Print Name d J+aL/fd G C bU W /4 Date // b <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE, ADDRESS: <br /> WORK PLAN DATED: �7 <br /> Application Accepted By Date Issued 1 f q� Area <br /> Grout Inspection By Date - 3� 060 Final Inspection By <br /> Date <br /> Destruction inspection By Date <br /> COMMENTS I CONDITIONS: <br /> L[ACCOUNTiNG ONLY: AID# I { <br /> FAC# <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PE <br /> RM€T 1 SERVICEREQUEST# INVOICE <br /> � <br /> ��- <br />