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WELL''ERMIT 1'I KATION FSM SITE <br />S-,� <br />SAN JOAQUIN COUNTY tIv R0"l1M YNSFtvvR'� I�%TION <br />ENVIRONMENTAL HEALTH DEPARTMENT ( HDp „P1 <br />304 E. Weber, Third Floor, Stockton, CA., 95203 JUS 14 <br />TILE <br />12,25 <br />(209) 468-3449 9OPY <br />NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br />4pplicadon is hereby made to San Joaquin County for a permit to construct and/or install the work described. This apptication is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 a``nnd�d the Standards of San Joaquin County Environmental Health Dep artment��or�s . u • L� <br />NELL Location CS 1,I: t,� LS. �'(1�LCross Street g� y -S _City zl.i; _zip S�3 Parcel# <br />2,0 <br />/ Ci Zl x•5.370'hone#_X r-i5I• 60O 5 <br />DROPERTY Owner �„Y Q� �y Address s ty'�— ._p, P <br />,-57 Contractor��51�r Address 23_ Ste= x, % City 5 1;1C.Zip <br />,^) iLic#-b X033% <br />Consultant/Sub Cntr r \ �_ Address�7 SI�Qa•-� Cfiy S tILi7S�Lic#_ ��y0}%phone# �� -!�i/ /(f/iC7 <br />GIS Coordinates: X <br />,Y Township _ Range_ Section <br />NORK TO BE PERFORMED: DESTRUCTION (choose type below) <br />NEW WELL/ BORING (CPT OPROBE, HYDROPUNCH; HANC-AUGER, OTHER') [I OVER -BORE <br />, OIL BORING # IIIPRESSURE GROUT <br />W ELL # \- <br />'Other. Grout Speafications: ���1' O� e11'1 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />p MONITORING 11 HOLLOW STEM DIA, OF BOREHOLE // MULTIPLE CASINGS? 0 MULTI-LEVEL? ff WELL CASING DIA:_ <br />J EXTRACTION 11 AIR HAMMER/DRIVEN CASING THICKNESS TYPE CF CASING: 0 STEEL (l PVC BOTHER --- <br />11 <br />OTHERQ VAPOR o MUD ROTARY DEPTH OF GROUT SEAL a tI TREMIE TYPE TO BE USED: O AUGERS HOSE <br />B AIR SPARGE i Ozone 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />1OILBORING HAND AUGER - GROUT SPECIFICATIONS:_ In A C-2V�/�4-`� <br />0 THER: - _ j OTHER A? ��� . APPROX. BORING DEPTH .Z Oy 0 BOLTED TRAFFIC BOX or j] STOVEPIPE <br />)` o t] CONDUCTOR CASING PROPOSED? /V (if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />r r-% <br />Signed jY //.VV I�� lvI w N' <br />Print Name }/ V IV k -5 r ^nnwoTMCAIT I ICF ANI.y Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: nL"� of <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Inspecdo. <br />COMMENTS If CONE <br />Inspection By <br />C-57 ✓ WC ✓-WA1VER_ C -b7 Letter OT AUTnomLanvn_,v>,yn Pu -nn, �••..,. ••••�••• ..- <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # RE 'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />C-57 ✓ WC ✓-WA1VER_ C -b7 Letter OT AUTnomLanvn_,v>,yn Pu -nn, �••..,. ••••�••• ..- <br />