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1 �, jan Joaquin County <br /> Ann <br /> Environmental Health Department n=k�9 <br /> 600 East Main Street, Stockton, CA 95202-3029ITTION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov-org(ehd JAN 11 . <br /> 1 <br /> ot Well Permit Application V <br /> NOIIAEFtIIw MLE PERMIT EXPIRES I YEAR FROM DATE ISSUED R� <br /> AppleaUont Is harehy mads to San Joaquin County for a pem*to corsbuct and/or instal the work described. This application is made In compliance wO Sen <br /> Joaquin County Deeelopr w t Title.Chapter 9-111&3 and the Sbrdards or San Joaquin County ErMromwwrW Heell Department <br /> WELLLoauon �A9 Street cityy n q. <br /> Zlp�£J • !O'�.Z <br /> Owner l ! ressL�71 elj cly 2%S) LPWea <br /> C-&7CWr&doAkj V el l Addrw3kA ssasACib�_9LU� $ Phoneal <br /> Conaullant l sub Cntr ()J� Address ` 7 w ZT41 Illy 5 P Llcat �LPnonmCILV SJ I-J`%>O <br /> Isis Coordinates:X Y Township Rar4p Sector <br /> d NEW WELL I BORING MU GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER- STRUCTION (choose type babes) +I <br /> o SOIL BORING s OVER-BORE, DIAMETE <br /> © *PRESSURE GROUT V. <br /> GROUT SPECIFICATIONS., <br /> �o <br /> COMMENTS: t-- rii ies6w <br /> TYPE oR t11ELl_ INSTALLATION TYPE COMSTRUCTIONAMFICATIONIS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLF,__„ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL d PVC 0 OTHER: <br /> O VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: u AUGERS a HOSE <br /> Q AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yoe p No (NOTE:MA)UMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING u HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:_ n OTHER APPROX.BORING DEPTH p BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (ff YES,Nat specifications in oon um t section) <br /> COIat1ENTa: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORIQNG HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby cotK11 that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County ,Ru1es Reguladons,and all applicable Call Laws. <br /> slaved x J TbWA)mpany <br /> Pr"Name g P a n M+ `IM QA Data <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 51 S 7 &A,5.A..rs. 4! <br /> WORK PLAN DATED: fly <br /> Appliadon Accepted Date Issued t 1 1.1 I,6 Aroa <br /> Grout Impec6on By Date Final Inspeetlon By Data <br /> DestructionMU922Dente <br /> c�IMlErrrsr oo�rorrbnra: <br /> ACCOUNTING ONLY: AIDS FACO <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT 1 SERVICE REQUESTS INW4CE <br /> s'taZ $# yos� v�'�y JAf I/ b SRO 190 <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit-i:::fEncroachment doe_ <br /> Ew 2m-wi WEB <br /> 9111=7 <br />