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• FIFTH FL00R <br /> WELL P 0 PAGE 02 <br /> N ERMIT APPLICATION FORM <br /> SAN JOA SITE <br /> ENVIRONMENTAL HEQUIN COUNTY MITIGATION <br /> 304 R ALTH DEPARTMENT (EHD) <br /> Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 <br /> Application is hereby made to San Joa NON-REFUNDABLE PERMIT <br /> Joaquin CountyD qwn NON-REFUNDABLE <br /> permit to con EXPIRES t YEAR FRO <br /> Development Title,Chapter 9-1115.3 cons and/ M DATE ISSUED <br /> 2,,,,, and the Standards or install the work descdbeE This a <br /> WELL Location ,xCO3 ��,�y �/ rro11f San Joaquin County Environmental HealPh�pe ar is made in compliance <br /> Cross S W partment. Pliance with San <br /> PROPERTY Owner Street �Ic�s/: �{ty S klw. <br /> �4 ..% � Assessor's <br /> AA Address PCZ $_ W,14 hh) Zip- Parcel#_— <br /> C•57 Contractor �}y Address City IJP LP � i Phone#lZs3 W.-,-,,,,- <br /> Consultant/Sub Contractor , a Z-4- �,A +4dCny —Zip 0c# Phone# <br /> ` dress 3C C K;4c" In —� <br /> GIS Ccorcina:es:X ��•(1Y — —CiTy��I-��OC#--0—Phane# �5'�' <br /> Township <br /> WORK TO BE PERFORMED: --�Range—Section <br /> NEW WE—!BORING(CPT.GEOPROBE,HYDROPUNCH,HANDER,OTHER-) <br /> D SOIL BORING# [I DESTRUCTION(choose type below) <br /> a WELL# 11 OVER-BORE <br /> 'Other. Grout Specifications: 7–bd& J cpc. I [I PRESSURE GROUT <br /> COMMENTS: - '._ s�, ea b ri ,� �roJe�w <br /> aH yr y <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONrrORL\'G a HOLLOW STEM DIA.OF BOREHOLE H'r MULTIPLE CASINGS?D YES f NO WELL CASING DIA:_ <br /> D EXTRACTON a AIR HAMMERrDRY_N CASING THICKNESS TYPE OF CASING: p STEEL p PVC D OTHER: <br /> fl VAPOR MUD ROTARY DEPTH OF H GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS D HOSE <br /> 17AIRSPARGE 11 PUSH POINT GROUT SEAL PUMPED: 0Yes !ANo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> SOIL BORING `(HANDAUGER GROUT SPECIFICATIONS: A 741 C-� i <br /> �OTHER: fl OTHER APPROX.BORING DEPTH d(I BOLTED TRAFFIC BOX or 9 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> -COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have p epared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules a�Regulations, and all applicable California State Laws. <br /> Signed x �J I�JJ1I / f Title/Company <br /> Print Name Yn�` �I-c��nc1�5 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORKPLANDATED: )DW1-- �(02w63r add <br /> Application Accepted B /� D@toIssued 40/OZ Area rUpt✓[s<r} C <br /> Grout lnSpecCon By pYIC � Date G2 Final inspection BY Date <br /> Destruction Inspection By Date <br /> COMMENTS I GOND(TIONS: 6 W. S <br /> et,rtt �N�o�ce <br /> �\O� DATE - PERMSi I SERV\GEREOUESZ# <br /> OZ SR# 603ooSo <br /> D 1/25/oz <br /> �,t �,m�t�Er�cCoachmec�t docs <br /> h0t.`C� \ontcs9�P <br /> / L P� <br />