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-.. SAN JOAQUIN COUNTY JUL 12 3 2010 <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT <br /> c 600 East Main Street, Stockton, CA 95202-3029 ENTVT�I EALTH <br /> • Telephone:(209)468-3454 Fax:(209)46&3433 Web:Www.sjgov.orDlehd f L CES <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDAB F PERMIT FYPIRFR 1 YEAR FROM DATE ISSUE <br /> APP9ca5on IS hereby made to San Joaquin Counry for,a permit to c Struct wMlor ImWll the work described. Thai application Is made in oompllenca With San <br /> Joaquin County Devalopnenl Title,chapter 8-111 5-3 and the St"wda of San Joaon Ccunty Envlronrmntal KOM Department. <br /> WeIlLocatlon 431 1411 Attie Ae.Croessimet [.ILYyWy p,g,,, city Sh'uAxA Zip 7- ass Paa"I#1T9LYOf7 <br /> rroperly Ownecj•{lsurwr TMVhfawlNLe,( Address _�tfll �.LI•./I.M.yam cm, 0---n Zip 9Y572 Phone# 9tf.S`YS.23y9 <br /> Ma..t. t pt.y <br /> GST Gontractcl' f.4aC�.ta On�� Addreais _ }L3 S- O,r.c CAsfc CRY AAi1- �ZPWIP�#tL&.G IIG1PIwne <br /> ConaueantlBub Cnb Ari Addroaa 9M L/s.e D..'.c S✓r)<µYChy 6y&' • LIC# Phone tr(.9l3:LJ7t <br /> 013 Coorelnaba'X ,Y ,Township Range Section <br /> VORK TO BE PERFORMED: <br /> NBWWELL1BORkIG ICPT,Q{1EOPROBE.HYDROPUNCH.HAND�AUPER,OTHER•) O DESTRUCTION(CHOOSE TYPE BELOW) <br /> •�SOR BORING# ((a7 MPT 4'1 YtY•`y) LIl)N�hL.Lw r.alla L1 OVER-BORE DIAMETER <br /> U"OTHER ( )n'.,,, tom` 11 PRESSURE��) _ GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CAO <br /> COMMENTS:_Cs t{P r 4bal% lA A }„ l Oa• 3 D p b e+ln\] {O l Or 1 1-+tft (}� . �s• SL =e s' ) 6k-+�.tl] <br /> C It's. Ko 52.. 6 LwtMI L.L.I.r.' �t �.,• 1 .__l ti wt] (1raA lb' a.2 Lo' <br /> TYPE OF WELL INSTALLATION TYPE CQNSTRUCTION SPECTIONS <br /> ❑MONITORING OHOLLOW STEM DIA.OFBOR�EHOLEI .l.v. [MULTIPLECASWGSOMULTIIEVEL WELLCASINGUke <br /> O EXTRACTION ❑AIR HAMMEWDRNEN CASINGTHICKNE39 yy % TYPE OF CASING:O STEEL If PVC O OTHER _ <br /> (3 VAPOR 0 MUD ROTARY (apt 0.31 V <br /> DyEPTH OF GROUT SE,I f O-aV TREMIE TYPE TO BE USED 0 AUGERSJU HOSE <br /> ❑NR SPAROFAZONE PUSH POYVT IGP OR CPTNK�pG` 14 e. iu yJ Ci) b-ty' all <br /> �! )_ ROUT SEAL PUMPED:9 Y« O No(NOTE:MAXIMUM FREE-FALL DEPTH 13 30') <br /> O SOIL BORING 0HAND AUGER GROUT SPECINCATKINS 0tcA Ce n,a,+ (wlS) Ctt...r(ter r <br /> IFOTNERSt[!♦- ,,DO 0OTHER: xBOR��DEPTH SI. BOLTED TRAFFIC BOX OR 0STOVE PIPEaoNotii:T ) <br /> 9rt YU,tM.PeWdkra M mmnwt rcYen) <br /> COMMENTS:I r.w,U(SJ- !t' `J 7.� 1t•11 c uL 'TdT 4Hl AT )[' llr.� r J r a L2 LFb-L.. 1 s ill) <br /> r r _ ate_ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING NOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hveby Fa ft that I haw papMW thh application and eut the work will be dom 1 accordance with San Joequln County Ordlmnwa.Ru6S and <br /> Rapulatbm,and RA pPIk CatlforNa Laws. <br /> sorted TIIWComparry771� <br /> Print Name BKM .L'..al.61e/ Dale <br /> DEPARTMENT USE ONLY 's <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORKPLANDATED: -ZC'tg MA.e( 2 Ze( <br /> APPLICATION ACCEPTED BY DATE ISSUED 3' 23 AREA <br /> GROUT INSPECTION BY _� 7-LP6 FINAL INSPECTION BY��w.n C�1� DATE I I L2S f I/ <br /> DESTRUCTION INSPECTION BY DATE l�- <br /> COMMFUJTSICONOITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECVT)BY DATE PERMR/SERVICE# INVOICE ;.. <br /> So( vl'v ej p 2 $ his /o SR# 60588 <br /> C57_WC -WAITER C57 LETTER OF AUTHORIZATION TO SIGN PERMR ENCROACHMENT DOC_ <br /> EHDZ 0110.rlfV0a <br /> WELL PERMIT APP <br />