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WEL6,PERMIT APPLICATION FSM <br /> SAN JOAQUIN COUNTY SITE <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 [ u „�. { {i; I � <br /> Application is hereby made to San Joaquin <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> County for a permit to construct andlor install the work described. Tiii'.aPpfica.ticn,is i add n'Fompliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental l e I1h F3epar fi <br /> WELL Location ZDT) w, vAw Gross 5tree a"�"`° Cif C. , ,assessors <br /> v Zip RS_ a�1 z Parcel# �� � )� <br /> PROPERTY <br /> Owner 11�T Address IDD ��t �6wn_ Cit ( � <br /> Y '7Qf•AZipIpr.%Z� Phony's 44r2-3� <br /> C-57 Contractor teCis-im Address j03I 604x A~ City +cif ! Zip 1 8� Lic# V Phone# .71D_ <br /> ! 1 l 2J— <br /> Consultant/ <br /> J -- `�S7S <br /> Consultant/Sub Cntr �+�15 &i'11). W �in1, Adre,[aNy� �p �vik pity vrr{�rv1 1� �t�GAL phonen S,LQ-�i7�-�p�Z <br /> GIs Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> `[ANEW WELL 1 BORING (CPT, GEOPROBE,HYDROPUNCH, HAND-AUGER, OTHER•) t] DESTRUCTION {chocse type below; <br /> SOIL BORING# CPT-1 � t_F>T Z <br /> 2DIAMETER OVER-BORE. <br /> []WELL# <br /> []"Other 0 PRESSURE GROUT SPECIFICATi0N5 GROUT <br /> COMMENTS: <br /> TYPE OF WELL. INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> (] MONITORING [] HOLLOW STEM DIA.OF BOREHOLE-- []MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: <br /> [] EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS. Al-q TYPE OF CASING: <br /> [] <br /> i STEEL 0PVC 0OTHER: <br /> []VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL 74 TREMIE TYPE TO BE USED: HANGERS <br /> []AIR SPARGE/OZONEPUSH POINT(GF or CPT)GROUT SEAL PUMPED: ` Yes []No (NOTE: OAAXIMUM FREE-FALL DE T1yH 1S 30') <br /> SOIL BOR{NG DHAND AUGEP GROUT SPECIFICATIONS faa+ n,k t Lvf/ C/eIr�.i{C S�vII <br /> []OTHER: []OTHER APPROX. BORING DEPTH [�� _€7 BOLTED TRAFFIC BOX or {] STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,iist 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 Regulations, and all applicable California State Laws. <br /> Signed x Title/CompanyW t <br /> Print Name1M Date L� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: s, <br /> Application Accepted By1Ok,, � Date Issued &//310 Area 97 <br /> Grout Inspection By �`�1' Date Final Inspection By <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS l CONDITIONS: Lof SLtkp Lcc( <br /> ACCOUNTING ONLY: AID# FAC# 00 7 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br />