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Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Well Location �2_42- 5'e- �tffaiv e"' Assessor's <br />2 7 <br />Cross Street city ZID Parcel # <br />Property f, ZIP qZ& ZIP <br />Owner Address S39 City W(A <br />C-57 Contractor C-Arton DnivviL Address CJC�0 4�A&A� city co,h LIC # <br />VK5r- <br />ConsultantfSubCriltirmoix Address.1 J) --j CAAA ) %0 City U0111 �*Phone <br />Township Range Section <br />GIS Coordinates: X 0 JPL <br />WORK TO BE PERFORMED: <br />0 NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) DESTRUCTION (CHOOSE TYPE BELOW) <br />C] SOIL BORING# VER -BORE DIAMETER <br />0 WELL # [I PRESSURE GROUT L <br />❑ *OTHER GROUT SPECIFICATIONS K 0AA14A*- <br />COMMENTS:—iP <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORINGOLLOW STEM DIA. OF BOREHOLE ❑ MULTIPLE CASINGS [I MULTI-LEVEL WELL CASING DIA:.�___ <br />0 EXTRACTION -OLLOW S <br />O AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: [I STEEL [I PVC 43 OTHER <br />[__1 VAPOR 0 MUD ROTARY _ DEPTH OF GROUT SEAL _ TREMIE TYPE TO BE USED 0 AUGERS [I HOSE <br />0 AIR SPARGE/OZONE 0 PUSH POINT (GP OR CPT) GROUT SEAL PUMPED: 0 Yes [3 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />–0/OTHER: 0 OTHER: APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list spwAcations in oomment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />I hereby certify that I have pared this application <br />"I've I <br />and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all a 191 7114pirnia Laws. <br />P P"i <br />Signed <br />Title/Company <br />U <br />Print Name <br />J Date V -2f <br />Nj <br />USE ONLY R��cp � <br />DEPARTMENT N 7 - <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />2nn, <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY PDATE <br />ISSUED ILUCTEA <br />GROUT INSPECTION BY <br />HSE <br />FINAL INSPECTION BY r <br />r <br />DESTRUCTION INSPECTION BY <br />ADAYy <br />DATE JEW <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK# RECVD BY <br />DATE <br />PERMIT/SERVICE # <br />INVOICE <br />Z2— <br />D/��/SR# S5 ko-q <br />C-57— WC -WAIVER <br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />EHO 29-01 11/5/07 (WEB) <br />WELL PERMIT APP <br />