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WEL PERMIT APPLICATION F RM <br /> SITE <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH 'DEPARTMENT (EHAE CC.E=TION <br /> .304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> . (209) 468-3449 DEC „ 2U05I <br /> NON-REFUNDABLE_PERMIT EXPIRES 1 YEAR FROM DATE ISSWAVIROWIENT H <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This a i Bance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Heal" <br /> i ` p t h. ,{ Assessors! �y <br /> WELL Location_l�_N E 5 T,-c { µCross Street wfij� Ayew'-City S clm Zip SZ�S. Parcel# 153 i p0-o i <br /> PROPE Y ,� <br /> Owner ddress ptV l � 15'obz Cit6a(/uf�lD Zip SO$1 Phone# <br /> C-57 Contractor CrD Address- I Jy' Iz-moi e f(� .wabl c47 r r�Zip. 0 ic#A.013Phgne � (0%1055 <br /> Consultant I Sub Cntr J'tfwnJ`) E V,!D 1w'1Pi11''A"ddress M5bCg 0�rM� ,-Qf. City t Cl 7 Lice 'Vhone# '5j()-(176- 'Zb2 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER*) a DESTRUCTION (choose type below) <br /> B SOILQRING# j rd �T 9 [I OVER-BORE. <br /> DIAMETER f M t <br /> 0 WELL# XRESSURE GRO T <br /> ©'Other GROUT13 em vm r .oF} <o ix;�) <br /> SPECIFICATIONS <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING U HOLLOW STEM DIA.OF BOREHOLE 2 i 0 MULTIPLE CASINGS <br /> []MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS r TYPE OF CASING: O STEEL O PVC BOTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEA LBS `ISO„ _ _TREMIE TYPE TO BE USED: O-AUGERS WHOSE <br /> U AIR SPARGE/OZONE 11,4�USH POINT(GP or CPT)GROUT SEAL PUMPED; \KYes g No (NOTE- MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING B HAND AUGER GROUT SPECIFICATIONS_- I .I GLA leiu; ( ;iq S—/7G F_W <br /> OTHER: _[I OTHER APPROX.BORING DEPTH S s'-isv Q BOLTED FIC SOX or d STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,.list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 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 Ord[ antes, R les and=ns, and al#.applicable California State Laws. <br /> Signed x II Title/Company "be— ['j y <br /> `� <br /> Print Name 6't7I 4 Date r 2 0 S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV-FILEq DR SS: <br /> WORK PLAN DATED ! b <br /> Application Accepted B Date Issued 12-17-7-11 Area g <br /> Grout Inspection By `l Date I )b Final Inspection By <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE J <br /> 3So y - 8 y Meg zr . O B t/.StsOz- <br />