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""*wSan Joaquin Count <br /> x <br /> Environmental Batt � . . . <br /> I <br /> 600 , Main Street, Stockton CA 95202-3029­­, <br /> Yom, (2 9)468-3449 Fax: 209) 468-343 Web: www,.lgov.org/e.lid K . IVWell Permit Application " <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED' <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work desphbed,�This`application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9"1115.5 and the Standards of San Joaquin County Environrn,ental Health I epartm pt. <br /> Assessors <br /> WELL Location s` .. A I C, t tit AY C: <br /> _Cres;Street >: i 1%, City aY k E r,r tt 6 ---Zip 5 r.(I.. ParceNt—­­- <br /> PROPERTY <br /> t Phone _ <br /> C7vrraet t,. 'C* ` ' _ Adtrass ,°' v ', City t L ,I�C) Zip;r * `f a .w " <br /> -557 Contractor ir )4 4 t AddressQ tt t 4x 1 „. Cityt R 104L Z gyp Limi »Phcse## a} 3L— <br /> Lk <br /> Consultant t Sub C ntr R,A t o Q qtr. t t t• Address_` tI t IL r W 1 F C€ty P till:. Us#§;`L*" � Phar a '� <br /> I t,€ <br /> GIS Coordinates: _ .,Y Township_—.-Range ._Section--- <br /> RK TO BE PERFORM1RMf D.x° <br /> NEW WELL I BORING (CPT,GEOPROBE,HYY ROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type below) <br /> SOIL BORING#& OVER-BORE, DIAMETER____, <br /> WELLI' 0 PRESSURE GROUT <br /> GROUT SPECIFiCATIONS­__ <br /> C MMENT S <br /> PE OF WELL I STALLAnON CONSTRUCTION SPECIFICATIONS <br /> 1101tlT F2( G HOLLOW STEM CTIA,OF BOREHOLE t' a MULTIPLE CASINGS [ MULTI-LEVEL WELL CASING CLIA;.,Z -_._. <br /> ESC`RACTION AIR HAMMER/DRIVEN CASING THICKNESS__ Eft , .,_TYPE OF CASING: l STEEL IPVC l OTHER:._.__. <br /> VAPr R MUD ROTARY DEPTH OF GROUT SEL �*� C,I TREMIE TYPE TO BE USED: j AUGERS a HOS <br /> Ally SP RGE1 OZONE l PUSH POINT(GP or CPT)GROUT SEAL PUMPED Yes 01do (NOTE: MAXIMUM FREE-FALL ETI I ' <br /> SOIL BORING a HAND AUGER GROUT SPEClFICATIO tib .tt`t <br /> OTitEt _ OT ER � AF'PRL7 ,BORING DEPTH q; BOLT TRAFFIC'BO r ( S7 3VE t�9PE <br /> CONDUCTOR CASING PROPOSEG_ (if YES,lost specifications in comment section) <br /> OFFSITE1PERMITS040100 <br /> 48 WORKING l URS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance ith Sart Joaquin <br /> County' rdirt S, Rules rtd ul tl rl ,and all applicable California State Laws. <br /> 1 <br /> S fined Title/Company <br /> yaany It�,. L t <br /> � . <br /> Print Name t�'i 1� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: "ifs <br /> WORK PLAN DATE <br /> Application Accepted Ey Cute Issued— ---___,Area <br /> Grout inspection S C7at :F "'� t"� Final Inspection By <br /> Destruction Inspection By Data <br /> COMMENTS t CONDITIONS: <br /> ACCOUNTING ONLY- AID## FAC## <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK## RECID BY DATE PERMIT 1 SERVICE REQUEST# NV?ICE <br /> `o � d ; 60q00 <br /> �o _ -- ,- <br /> "m57 WC__-WAIVER— - Letter of Authorization to sign permit mit—­-"Encroachment ac <br /> EliD 9-ti"-00k eb <br /> 6!22,'04 <br />