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�J J `UJ4bt:-�4j3 FIFTH FLOUR <br /> PAGE 132 <br /> WELL r-ERMIT APPLICATION FOivA <br /> SAN JOAQUIN COUNTY rENVIRONMENTAL HEALTH DEPARTMENT Z41&TION <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 U� IT IV <br /> (209) 468-3449 JAN I 2003 <br /> NON-REFUNDABLE PERMITEXPIRE81 YEAR FROM DATE ISSUICOENVIROMIENT hE/._ <br /> AG>I�ation is hereby made to San Joaquin County for a permit to constructand/or instail mha work descrired. This appllCPEP'S1 F„ 'I4 <br /> Jo,quin,Count/Develcpment Title.C,,{h��aptar g-1115.3 and t1e Standards of Sdn Joaquin County Environmental Health Deparment. W' rIiACe Nith San <br /> WI LL Locatlon �Ll 0 ULe#0Cross StreetSl�J9�/► l'✓ Assessors/�/- 2SlJ ` Z2 <br /> �fI�// City Zip 95330 parsers <br /> PF OPERTYOwne- CYwj!4 (la� tiJ C-v q� Add.`ess 09 9-3 J � <br /> C g N v r - — City � ,/' Trp GJ'S 33J PhvneF <br /> C-•7 Contractor Gov /dry{1�l Address d!q 8 F'aaj 1) 5tt3' S 0 — <br /> 1 `�iry RDSetI� Ileyia QSY7Li,��cr'3-sLPncne� 5'/G`S2cf-1Z70� <br /> Cc isuitant i Sub CntrJ V Address T'J 2 `r 7 <br /> r� O 3/(� _ c`tyr�„�T LicJd � Phone �0 S rr s�� z <br /> GI i Coordinates:X �'J Y y/ y� � Township / S Range G Secron �y <br /> Wr IRK TO BE PERFORMED: <br /> p I IEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type t <br /> Q SOIL BORING <br /> :)VER-BORE, DIAMETER <br /> 0 WELL Q PRESSURE GROUT <br /> Q`Other _ _ _ <br /> CC h1MENTS: GROUT SPECIFICATIONS <br /> TY'E OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> IONITORINS -*IDLLO'N STEM DIA.OF BOREHOLE Q MU-TIPL_CASINGS 0�AULTI-LES/EL WELL CASING DIA; 2- <br /> 0 <br /> 0 t XTRACTION a AIR HAIAMERIDRIVEN CASING THICKNESS C-yQ_TYPE OF CASING []STEELPVC Q OTHER: <br /> APOR a MJD ROTARY DEPTH OF GRCUT SEAL TREMIE TYPE TO BE USED: O AUGERS []HDSc <br /> []s IR SPARGE/OZONE [I PUSH POINT(GP or CPT)GROUT SEAL PUMPED: []Yes G Ne (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> C:OIL BORING 0 HAND AUGER GRCUT SPECIFICATION$ Lei Z-� A_ <br /> (]( THER 13OTHER APPROX.a0RING DEPTH BOLTED TRAFFIC BOX or Q STOVE PIKE <br /> CONDUCTOR CASING PROPOSED._ (If YES,Us:speafIcakns in comment sec-dor) <br /> CC MMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 11,dreby cel*fy that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> C( unty Ord es, ul s and Regulations, and all applicable California State Laws. <br /> Sic led x ,L(it(�(wL� Title/Company <br /> Pri t Name 0 It l� Lt. (,V,vL; Qd;e <br /> -2", l� <br /> DEPARTMENT USE <br /> �ONLY <br /> SI"E MAP IN UNIT IV FILE,ADDRESS:_ / `I l6 /LII <br /> W )RK PLAN DATED: ' / C� <br /> Ap iicatlon Accepted By_ ' Date Issued ` /oZ ` �3 Area T y <br /> Grc ut Inspectio-1 By Date Final Irspect on By Dam <br /> De truction Irspecton By <br /> CC HMENTS:CONDITIONS: n rIOVI ng we I L5 D 2-$ IYl 61T f/1 <br /> A COUNTING ONLY: A10# FAC# <br /> P :CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT r SErtVICE REQtaEST# INVOICE <br /> j3 SR# 3-) z <br /> C-57 WC -WAIVER— C-57 Letter of Authorization to sign oermit_Encroachment doc� 9/30/C2 <br />