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'FILE <br /> COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY <br /> MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT-(EHD) UNIT !v <br /> ,; . ,._t <br /> 304 E. Weber, Tkird Floor,'Stockton, CA., 9 ' <br /> --- (� - , .(209) 46.8-3.449 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> Application is hereby,made to San Joaquin County for a permit to constru t'andlor 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 Heatth Department.' <br /> Assessors <br /> WELL Location ti 5(�(� {Sln(�liJ 2[S,, . Cross Street E-&C - Ci y� _Zip S �S Parcels 1 3` O <br /> PROPE T /► <br /> .. Owneri �TC� ( �ddress41�i� �/,�.- W1QrltTrZ .Cirye 7Upp' ,_Phanek;` <br /> t - -. .. gr� C-1 J <br /> C-S7ContractorL. I n Address�3) ..6Y1/I . �kr' ,j ; City '(k Zip�5.-JV�2Lic#Irl5 Phonesa`l(e�(1 c-IIIo`I Y,s <br /> Consultant/Sub Cntr�Cvi,.�I i[!.��ftif'i'�n .�(APl10E�Afldress�e3aJ�YYI0�,1�1� City_1�_Licr Phone_ <br /> �:� <br /> GIS Coordinates:X J7 �Z�OJ1;v� ,Y I Ri. 84 R(4q ,Township carr k i Lin Range 'k Section <br /> WORKTO BE PERFORMED: A'`! <br /> ONEWWELL 1 BORING (CPT,GEOPROSE,HYDROPUNCH,�HAND-AUG=F�;OTHER-) DESTRUCTION '(choose type below) <br /> 0 SOIL BORRIG# OVER-BORE. DIAMETER <br /> ,VW-LL�1q.F-,��-.,,gb-• n C- t'3 1 3 W S1, V 1-5 (]PRESSURE GROUT <br /> 4 0*Other GROUT SPECIFICATIONS r v <br /> COMM=NTS: <br /> s0 <br /> TYPE OF WELL INSTALLATION TYPE CONST RUCTION SPECIFICATIONS ^ <br /> " <br /> MONITORING 4i='YHOLLOW STEM DIA.I�OF BOREHOLF 8 [i MULTIPLE CASINGS Ii MU`Ti-LEVEL WELL CASING DIA!`9 <br /> -.. EXTRACTION 0 AIR HAMM=PJDRIVEN CASING THICI NESS SC o TYPE yOr CASING: 0 STEEL PVC n OTHER: <br /> XVAPOR IJ MUD ROTAFZY DEPTH OF GROUT SE.ALALW-5� 17—"TREMIE T YaETO BE USED: j]AUGERS HOS <br /> A[R SPARGEf OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: as Q No (NOTE: MAXIMUM FREE-FALL DEPT IS 30') <br /> 0 SOIL BORING E HAND AUGER GROUT'SPECIFICATIONS )el C,0-to ri E <br /> 0 OTH=R: Q OTHER APP ROX.BORING DEP T H A.r ir!,��T�=(}�OL i ED I RAF:F!C BOX o;._0 STOVE PIPE <br /> CONDUCTOR CASING (�`i YES,listspecifications eions in obmment section) <br /> ti. �{yD , � <br /> COMMENTS: "! <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. F <br /> 48 WORKING HOURS.NOTICE REQUIRED FOR INSPECTIONS.F i. <br /> I hereby certify that I have prepared this application and that the work will be clone in accordance with San Joaquin , <br /> County Ordina s, es and egulations, and all applicable California State Laws_ + <br /> Signed x l �G,�C ctCf C �fl/s%%j i fe/Company uS Q I <br /> f �^ tt g <br /> ;Print Name C ry--a Date ! O � / k <br /> DEPARTMENT USE ONLY <br /> . <br /> SITE MAP IN UNIT rV FILE,AD R SS: j~�d <br /> WORK PLAN DATED: " r <br /> Appfi�tion Accented By '1, Date issued t�iy- e Area <br /> Grout Inspection By, Date Trial Inspection By <br /> Destruction Inspection By :I�Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAGr <br /> PE CODES -FEE INFO I AMOUNT REMIT Ed CHECK'n rt REC'b by DAT c PERMIT;SERVICE REQUESTr � INVOICE I <br /> SRS 0030 S " <br /> C-57 WC=WATVEi2— C-57 Lester of Au-thorizaiion to sign perm r= ierpaehm�nt doc,_ 9/303/02 <br />