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11110!2005 15 59 2094663433 EHD PAGE 03 <br /> WELL PERMIT APPLICATION FORM <br /> SAN JCAQi11N COUNTY SITE <br /> ENVIRONME YTAL HEALTH DEPARTMENT (EHD) UMITI <br /> NIT FVTIOlV <br /> 304 E Weber, Third Floor, Stoddon, CA , 95202 UNIT N <br /> (209) 488-3449 <br /> Application r5 herebyNON.r2EFLlMaABLE FEn"+IIMIT EXPIRES 1 YE4fi FROlN DATE ISSUED <br /> Joactuln CDun made to San.IoeGu.a County for a pe^tut fo can5tntct ariQ/or instal!the work described This application is made rn Compl�ar►ce mth San <br /> t5' eloprne Tltie,Chapter 9',_q 15 3 and trio Stan�nstr t,;San or i ual Co <br /> g b k f(_ 11 q urity Ermronmental Health Department <br /> WELL LocaGan f'� Cross 5treeti /�,q �} <br /> PiZOPA `Crty �"jf zJ Part= f 1D -�7 <br /> :.ddress Gty J�G <br /> } fi3)F'hDne <br /> C-57 Contractor i�; Address 1�wt �l �gqJ53 �c�q51� <br /> Consultant/Sub Cnt6 FSU, °Gar cr+► Dr, Cl P Phane#�GJ� I e-57DD <br /> Address , 5"i�C�$b <br /> GIS Coordinates x c` 1cL'�` `._._Phone# <br /> Y Tcwnshfp Ran <br /> ge <br /> 6 ORK TO BE PERFORMED Sechon— <br /> k,NE W LL!BORING ( PT,?EOPR BE HYOROPUNCM HAND-AUGER OTHER*) <br /> NAMETER Oil_BORING* ti Ndv� �- [l DESTRUCTION (choose type below) <br /> [1 WELL* [1 OVER-BORE <br /> )PECIFICATIONS0 PRESSURE GROUT <br /> :4MMENTS GROUT <br /> YPE QF WFLL INSTALL.A71ON TYPE CON RU <br /> Q C7IQN SPECIFICATIONS � (&41 ewp <br /> MONITORING i'IOLLQW STI;►VI DIA OF BOR>`!-IOLE <br /> _,0 MULTIPLE CASINGS 0 MULTI-LFVEI. WELL CASING DIA. <br /> ARGB AIR <br /> TION HAMMER/DRIVEN CASING THICKN?=SS ftd ftdluC <br /> )(MUD ROTARY ----TYPE O�CASING fj STEEL (]PVC [1 OTHER <br /> DEPTH OF GROUT 5F.4L TREMI!_TYPE TO BE USED_ <br /> AIR 5PARGE1 OZONE Q PUSH POINT(GP Or P7)GROUT SEAL PUMPED �Y�Da [I AUGERS <br /> %SOIL BORING 11 HAND AUGER NOTE: 1MUM FREE-FALL DEPTH 1S 3 '� <br /> OTHER GROUT SPECIFICATIONS <br /> OTHER AF�PROX BORING DE=PTT-[ II BOLTED TRAFFIC BOX or p STOVE PIPE <br /> 7MMENTS �e CQN GTOR CASING PROPOSED (if YES,Gst spaGtficatronr,rn cmment seCbon) <br /> u y� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS`h,ICgXE-REQU <br /> lereby certify that I have repared this application and that the work will be done in accordance with San.Joaquin <br /> 3ttnty Orth tions, artd all applicable Califomja State Daws. <br /> ined x_ <br /> TitlelCamParty <br /> -it Name <br /> DEPARTMENT USE ONLY <br /> rE MAIC IN UNJT IV FILE,ADDRESS' zj577.f <br /> TRK PLAN DATED: <br /> )(=tion Accepted 8y <br /> Lit Inspection By Date Issued Itli Q Area <br /> Date Final Inspection By <br /> Date <br /> tructtorl Inspection By <br /> Date <br /> 2 u S r CONOMONS <br />,`CING ONLY A!D# <br /> PAC* G�{�{ 77 <br /> CODES FEE INFO AMOUNT REMITTED CHECIf# <br /> REC'lb BY BATE PERMIT!SERVICE REQUEST* INVOICE <br /> 3Sr✓t � 8'� �9�"Y C �d r � <br />