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WELL PERMIT APPLICATION FORM SITE <br /> c d�'IFcCl I~ I,E�J;i_ Ff AL7iI SAN JOAQUIN COUNTY MITIGATION <br /> FEPH'r SP.WkONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 3� E ' eber, Third Floor, Stockton, CA., 95202 <br /> 03 JUL -9 Aft �: I� (209) 468-'3449 <br /> NoN4z1=FUNDASLE PP-RMIT EXPIRE 1 YEAR.FROM DATE ISSUEb <br /> Application is hersby made to San Joaquin County for a permit to constructBand/or install the work described. This application is made in complianm with San <br /> Joaquin County Development Title,Chapter 9-1115,3 and the Standards of San Joaquin County Environmental Health Deponment. <br /> Assessors <br /> y►p'[Location .I.f. 1k bj �53 ��y Cross Street �l I� City Wv a, Zip <br /> q5-33� Parcel# <br /> PROPERTYUwner 1'ASA% 1a A 71L�r'� r�dA� (a ' (�erfrr � c;ty. )ck-fon z �765Phon# 7 <br /> C-5-fCantravor �` r�rddress7�� ��i�� �Qc'� City oc Zip ���i k�$5, Ph C1 #S-3� ~S, O <br /> p FI lf7~LEO -LHr10 <br /> onsultartit uI5 Gntr� rt, [�i CrVl Address CI nak'lar''d 1_Ic1 Phone <br /> GIS Coordinates:X Y Tgwrishlp 3 Range iv —76 <br /> YYORI£TO BE t>ERFO1�tVl <br /> A I;7RING (CPT.GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER") DESTRUCTION (choose type below) <br /> `MSQIR BO f]OVERBORE. DIAMETER <br /> 0 WELL# R E S S U RE GROUT <br /> n*Other <br /> GROUT SPECIFICATIONS <br /> COMMENTS; A •. _fps —as i;z - <br /> TYPE OF VVELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONgNt, ujt a CJaI1j-u&+ Cs� �i� <br /> a MONITORINGIDLLOW STEM DIA.OF BOREHOLE�{r0 MULTIPLE CASINGS j]MULTI-LE�VFL LL CASING D'Ar <br /> 0 EXTRACTION 0 AIR HAMMEPJDRIVEN CASING THlcKNESS NA- TYPE of CASINO: a STEEL p PVC U OTHER, AA -- <br /> 0 VAPOR d MUD ROTARY DEPTH OF GROUT SEA j_411 (zckrfll TREMIE TYPE To BE USED: 0 AUGERS KHOSE <br /> 0 AIR SPRRGEJ OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )ryes p No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 30') <br /> XSOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER;` P,'OTHEF AP✓]FZQX, BORING DEPTH__' �f-t— Q'$@LTC'f]'iRAFF1t✓E3 ar C�1�PtPE <br /> CONDUCTOR CASING PROPOSED KA (if YES,list specifications in comment section} <br /> Comm k4 r X1411 a �� P ,m rd dt LAM S lrKeS. <br /> NOTE: OFFSITE BORINGS RE DIRE A CrZSS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> J hereby certify that I Have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or finances, Mules and Regulations, and all applicable California State Laws. _ <br /> Signed x 'ritlelcompan3 ' rz � �7�`l f . <br /> Print N e + PM)1!7- M <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATER: Cal Rid aL-4 w.P. IOr-� <br /> Applicatlan Acozpted By b4K Date Issued tU4? Areal_ <br /> Grout Inspection By. pate Final Inspection t3y Date <br />❑estructlon Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY' AID# FRC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECl4# REG'D BY DATE PERMIT I SERVICE REQUEST# INVOJCE <br /> C-57 WC -WA1VE;Z C-57 Letter of Authorization to sign perrnrt Encroachment dcc 9/30/02 <br />