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66/11/20e4 69 27 2094683433 FIFTH FLOOR PAGE 02 <br /> San Joaquin CountyCE U` L.rP4-,. <br /> nialental Health Department <br /> 3404304 as giber Avenue,3rd Flt , Stockum,CA 952x2 A U G 0 9 2004 N <br /> L (209)468_3449 Fax. (209)468-3433 Web: www,rjgov.or�ONMENT HEALTH UNIT IV <br /> --~ 1VQH-REFUNDABt�pEiiMR EXPIRES't YEAR FROM DATE ISSUE OERMIT/SERVIC <br /> tApplication IS hereby made to San Joaquin County fora permit to construct andfor Install the work'descnbed This appfi=bDn 6 made in compliance Ith an <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> �, _ Cross 5tireet- - — CdY P a C U, Possessors-- <br />'WELL Location I' .�Oe <br /> 2:04 6Z2:- <br /> PRQPE <br /> Owner YS dclressPQ-q <br /> + 7ct <br /> 57 Contractor dresstily � 0. l� �rW, SOnU4 <br /> lad j7 j�Ptione# ( 3a[1 9 <br /> �f101d� lfUi1L6Consultant/SubCntr —Addressdy�Lo.. Phonw ` IpL <br /> FIS Coordinates X Y ,Township R2ngy4 Section <br /> WORK T--BE PERFORM <br /> NEW WELL,/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) _DESTRUCTION (choose type below) <br /> SOIL BORING* n'6VER430P.E DIAMETER <br /> FWELL 0 X1'1 n PRESSURE GROUT <br /> 13*Other _ GROUT SPECIFICATIONS <br /> OMMENTS: Lea (5/f / raw s <br /> a} _ <br /> TYPE OF WELL INSTALLATION TYPE <br /> CONSTRUQDON SPECIF!pAlIONS <br /> C <br /> ONITORING HOLLOW STEM DIA OF 6OREHOLE�a'I]MULTI%E CASINGS p MULTI-LEVEL WELL CASING DIA. CK tr <br /> )CTRACTION p AIR HAMMER/DRIVEN CASING THICKNESSo 154° OF CASING II STEEL -0PVC. 0 OTHER <br /> a VAPOR n MUD ROTARY DEPTH OF GROUT S� TREMIE TYPE Tb BE USED D AUGERS OSE <br /> 1p"PARGE OZONE 11 PUSH POINT(GP or CPT)GROUT SM PUMPED 'I;Yes i No INOTE• MAXIMUM FREE-FALL DEPTH IS 30') <br /> FW BORING n HAND AUGER GROUT SPECIFICATIONS_ � - <br /> p OTHER _ II OTHER APPROX.BORING DEPTH �p. *OLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A01 (if YES,list speciflgtions in comment sectran) <br /> tOPAMLISIM <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS_ <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certrly th t I nave preps d this applica ' n and that the work will be dame in accordance With San Joaquin <br /> ounty Ordinan ,Rules a d egllia s, a all applicable California Stater Laws <br /> igned x 4 T7tIaJCcmpany .p(iejQ�rL /rl <br /> Iint Name_ 1 N _ 'room ll ti_ —Date Wo <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: rd� /• <br /> CORK PIAN DATED: Awl% • <br /> kppirGation Accepted By Date Issuer,_ Area <br /> rout Inspection By Date Final Inspection By Date <br /> estruction Inspection By Date <br /> ;06AMENTS f CONblreoNs <br /> COUNTING ONLY AlD# FACdt <br /> DES FEE INFO AMOUNT REM[TTED CHECK X RECD BY DATE PERMIT f SERVICE REQUEST 9 INVOICE <br /> 2_70L MW <br /> :-57 WC -WAIVER C-57 Letter of Authorization to sign perms Encroachment doc - <br />�D 29-02-0OI <br /> Ot?3 <br />