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02/1 //200b 14 lU 2U54b8.3433 EHL) 1"AUE 03 <br /> �Qs,r San Joaquin County �S � <br /> Environmental Health Department e S' 1 <br /> t 344 East Weber Avenue,3 rd Floor, Stockton, CA 95202 *10W006,(209)468-3449 Fax (209)468-3433 Web www sjgov org/ehdWell Permit Application rH <br /> S <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct andlor Install Inc work described This appllcatlon is made In compkanoe with San <br /> Joaquin County Development Talc Chapter 9-1115 3 and tttic Standards of San Joaquin County Env ronmental Health Department <br /> 1, <br /> Assessors <br /> WELI.Location _L�l D R We: Cross Streot g\yv+� City 5A"'-� ZIP ParoBltl O`Q —to 3 p 3 L <br /> 1ix�Jaw`.� <br /> PROPERTY <br /> OwnAr 4L �.s5o�ddress C,ly mo<4 5q_zfpo y5 tpltone#(az.5)Ll-k -'Z%n t <br /> Antillc.�.c>,.� <br /> C-67 Contractor �._ - ^address�lrZ q�`ne CltyR <br /> ��,eZ,p �4'Lca* Phone#( 11ca�_to. $�llb� <br /> Sic.-,.-+.r mar 'wk c..A.� <br /> ConsultantISub Cntr Fe ress3ot"1 �,_\ [Rd City Uc# PhonenVpQ <br /> u.ro. <br /> GIS Coordiriates X Y Township Range SeWv <br /> WORK To BE PERFORMED_ <br /> ,9NEW WELL 1 BORING (CPT,GEOPROBE HYDROPUNCH HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> $,SOLI_BORING# 13 OVER BORE DIAMETER <br /> p WELL# Q PRESSURE GROUT <br /> 1]'Other _ GROUT SPECIFICATIONS <br /> COMMENTS <br /> , <br /> TYPE OF_tNitLl 1NSTALLA710N TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING p HOLLOW STEM DIA.OF eOREHOLE p MULTIPLE CASINGS Il MULTI-LEVEL_ WELL CASING DIA <br /> 1)EXTRACTION 11 AIR NAMMERIDRIVEN CASING THICKNESS TYPE OF CASING a STEEL Q PVC I]OTHER t <br /> 0 VAPOR p MUO ROTARY DEPTH OF GROUT SEAL___L,__TREMIE TYPE TO l3E USED p AUGERS p HOSE <br /> 13 AIR SPARGEI OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED DYoa ➢No (NOTE MAXIMUM FREE-FALL DEPTH IS 30) <br /> 1sdlL 80R.1NG Q HAND AUGER _ GROUT SPECIFICATIONS Q��w�4v.k\+cb�.+�_. <br /> . t1 OTHER OTHER APPROX BORING DEPTH�fi+t?! 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (If YES,list specifications In eomrnant section) <br /> COMMENTS S `.k A - AS-1O <br /> /►^GoyC -1'?-oL t„ S` l�-cts�•bt <br /> NOTE. OFFSrrE BORINGS REQUIRE ACCESS AGREEMENT C'R ENCROACHMENT PERMITS, <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> hereby certify that I have prepared this appttcatton and that the work will be done in accordance with San Joaquin <br /> County Ordinances,Rules and Regulations,and all applicable Callfarn,a State laws <br /> Signed x < y_,_ ro. SC.�y,%V% 4^ Se r ssr -xre�_i!c"'we4AgvV'y <br /> Print Namea�-�-.�. vData `S.al. %. - <br /> DEPARTMENT USE ONLY <br /> $11 E MAP IN UNIT IV FILE,AQDRESS' <br /> WORK PLAN DATED' tf xc�Yw ..`_.r ` <br /> Appy liostlon Accepted B � �-. . +r as Elate Issued- �_ ! O r _Area. <br /> Grout Inspection By .. Dale Final Inspectlan By �7 Date <br /> Destruc4on Inspection 13y Date <br /> i <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AtD4 FAC* <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK 11 RECD BY DATE: PERMIT I SERVICE R9QUt~ST# INVOICE <br /> �yZ3�z z�- 8R# Lf f5- 6 <br /> C-57r„_, WC_____, -WAIVCR� C-57 Letter of Authorixotton to sigh permit_ Encroachment eoc„_ <br /> • 24 02 poi <br /> 6122f12r04 <br />