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Joaquin County FILI C <br /> z:. z Environmental Health Department SITE <br /> f N s6(�X 304 East Weber Avenue, 3rd Floor, Stockt n, CA 95202 u *iATION <br /> ' (209)468-3449 Fax: (209)468-3433 Web: w.sjgov.org/ehd 41k 1V UNIT <br /> v` <br /> IV <br /> 2008 <br /> Wel! Permit Application SR NT HE <br /> - <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDP /r/sL'j�4�4L1'H <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install thework described. This application is e in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin Co my Environmental Health Department. <br /> 232c Au e;-r. �- 4T <br /> pI� e3e_i6] <br /> 4Tj g52O Assessors <br /> WELL Location Cross Street ity. Zip Parcel# <br /> PROPERTY 2720 N,CmLIf=,�-t ST G1�7ON 9 SW ZUg1` <br /> Owner�'K• TAv4t� 74.t-1 S!44pbJ_Address � ,f � r City Zip horned#/� 1 ��'2C?� <br /> C-57 Contractor r/�Cf1T�L-�Address Z Co L 16W&— City Zip ��Lio#10Jf7 i hone 02-. <br /> oTH1 — N Sulu� fa ID AN-ri�IraP �7'io7 C lice 7z�-fl y <br /> Consultant 1 Sub Cntr � Er� Address��"d biL �� ity ic# Phone# <br /> 3 •g�5 .I . z4a <br /> GIS Coordinates:X ,Y I2 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL 1 BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# M W— 10 G 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIO IS 11 <br /> MONITORING „HOLLOW STEM DIA.OF BOREHOLE '3 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA 2 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 461-1 L4 CD TYPE OF CASING: a STEEL PVC 0 OTHER <br /> 0 VAPOR o MUD ROTARY DEPTH OF GROUT SEAL �o TREMIE TYPE TO BE USED: 0 AUGERS `'HOSE <br /> []AIR SPARGEI OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ;KYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING O HAND AUGER GROUT SPECIFICATIONS 0 10 P z.0 Rare qy 16 !;Ac _ GE;HE✓N T <br /> 0 OTHER:_a OTHER APPROX. BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREE WENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIR D FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the wok will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> ��Signed x �/ Title/Compa y <br /> Print Name Cr EL VG A Cr--e Date f 7,d <br /> DEPARTMENT USE ONLY N4�� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z�/y /U• <br /> WORK PLAN DATED: 0 Z�S <br /> Application Accepted B 4 Dati i Issued ° Area <br /> d6 <br /> Grout Inspection By Date_ .-..Final Inspection By Date sc—/-d <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3 3 156 ISZ ` N ISR sR# <br /> C-57 WC�vl WAIVER2 C-57 better of Authorization to s gn permit Encr Ment doc— <br /> EIdD 29-02-001 <br /> 0122104 <br />