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WE,.,, PERMIT APPLICATION FOWA <br /> SITE <br /> SAN JOAQUIN COUNTYmED RM" v �Wiv <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 MAR 21 2 <br /> (209)468-3449 ENVIRONMENT <br /> S�II rn���++qq� HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS U, &r�VtV,Vi�l 7 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application i M "�-1f�� AGSan Joaquin County <br /> Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ��y c� p CI <br /> Assessor's <br /> WELL Location�l7 A 5•�/ 110A✓O 7 Cross Street CIA /� DQ ./City � T;.�ZipgEZEi� Parcel# 1-79—�7�1-4'3 <br /> PROPERTY Owner 2k> " �/C/JI 6 Address'J/79 S- K��+// 1 City d Lap ip S Phone# 2o9 ?14 MS— <br /> C-57 Contractoli&lhQD tog& Address m 2� �'/• CityDT�nGfcZ�,�i zip S �c#��o1 2?Phone �9)�6 7 apo <br /> Consultant/Sub Contractor , (�. Address o J7 c�I� F{/ City' Lic#ra�u7 Phone# 2O`� 4 '7-606 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PER ED: <br /> EW WELL RING PT, PRO YDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> 46 L BORING# 0 OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z•P-�S`MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: S <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALT4 [�REMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE )(PUSH POINT GROUT SEAL PUMPED: Pas [INo (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: --I—vw— yuz —& <br /> & Ako <br /> 0 OTHER: Il OTHER APPROX.BORING DEPTH 10 P 3 !O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ^^''- '',, CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: L/ c5C�&Ak S �O 161 ./ Z SAlA4s Tv �p <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 I have prepay d this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> Rules a LF <br /> II a licable California State Laws. <br /> Signed x Title/CompanySrg�alp /�✓�lcC2 46ot� Vi��! <br />