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WELL PERMIT APPLICATION FORM <br />SITE <br />cl=p i0r�6 SAN JOAQUIN COUNTY MITIGATION <br />- ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br />PERIN11T/SERVICES (209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or 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 Health Department. <br />/I II // ll'' // __ Assessors <br />WELL Location'aSb 0 l e5A Loo. Avow- Cross Street 1 LyA Sacmmt )city W(�I Zip q5 � 47 Parcel# Do�7 y01�% <br />904 <br />PROPERTY n Cc � 1 G <br />Owner_ AKT Pro vA,' (5 Address -'loo (diegf 10wr1 X. City S46tW�NMU Zip g5s 2� Phone# / �ip- yV19-jj0 <br />C-57 Contractor W00 i��N Address S�Ikiil U <br />SSo Ri�r�1 Rd.. City io V' ZipcJ4S71 Lic#%10q? Phone#Z07-.37V- 7.3ob <br />< p,k Sv�SSo, ouvn � <br />Consultant / Sub CntrJ�(btJlyS ENV 1 rM Addres33v Cqv>7 t/►�1 1' �y City Lic# 44Z Phone# 5,Z -1! 76 �1�7 <br />GIS Coordinates: X 'y Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING CPT, �3EOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />'SOIL B R4NG # C(y IS_ <br />01 <br />[] OVER -BORE. <br />Q) <br />DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0.Other GROUT <br />SPECIFICATIONS <br />- / , / , wSM�IQ <br />COMMENTS: vi rrlJl l5 GtUAMUDy1 '�f'w1 A <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />tI <br />0 MONITORING ATOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 'fI%�-RU TREMIE TYPE TO BE USED: [] AUGERS eOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Ves 0 No (NOTE: MAXIMUM FREE -/FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 1VJ <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED fV (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />K-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 ulations, and all applicable California State Laws. <br />Signed x 11 c Title/Company % <br />Print Name F► G IN 00 w &4a,*S) Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By Date Issued ! /1 q 1 dr— Area! 9 I <br />Grout Inspection By Date �l�� f^� Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# I FAC# <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECK # I REC'D BY I DATE I PERMIT / ERVICE REQUEST # I INVOICE <br />3 so l 8 -7 - 102-10 /4t- qll ql,*6 6k# 0& yB 4d- <br />