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SAN JOAQUIN COUNTY <br /> !F4EIVTAL L+` LTH DEPARTMENT <br /> - <br /> SITE <br /> ' <br /> :kton, C '5202-3029 L <br /> Teiephors. (2'.1 '38.3,•4.; ,,,.. 1209* 468-3433 Web:wwW.siaov. MITIGA-BION <br /> UNII AV <br /> WE'LL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 •J!?+cSE¢ S�i2v- ,, ,> (i✓��� Gxu j' o ;�,J,C- _ t <br /> 2W' ``� Cross Street Assessor's <br /> Property, City ,.,,�.,�,y �. Zip �S,Z='� Parcel# /✓ _ <br /> Owner Address ev� fr y'`! -t�- '�� City Zip Phone# <br /> C-57 Contractor ''c:y /prvts %C�ti Address 31 LtJ' '✓:'t= ?.} C�+m+ <br /> City -�cc: f Zip f ( Lic# i ASK C' Phone S Sic <br /> Consultant/SubCntr fgoles;s Address '357/ vn y Vej$ t2tj• Ci 33a Lic# PhoneZJ-j ` <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) [I DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# I-�yc'' ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> El*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [IMONITORING r�'HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> Er''_,�SOIL BORING El HAND AUGER GROUT SPECIFICATIONS ne 4—",- "r <br /> 6? <br /> ,,VOTHER: r' LcJ ElOTHER: APPROX.BORING DEPTH ��'! IL=� <br /> ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED AA-) _ (if YES•list specifications in comment section) <br /> COMMENTS: T_P/Jm c� l'�rr�z . <br /> NOTE: OFFSiTE BORINGS REQUJRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Ruies and <br /> Regulations,and all applicable California Laws. <br /> Signed ryyt/Ccy�� y� C 4 Title/Company �r�r' �Gr�i✓1 �7`.;T <br /> Print NameZz i;� y,otrl Date 7 co/—C90 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: lA 1 k A+A S� <br /> WORK PLAN DATED: D Q <br /> APPLICATION ACCEPTED BY DATE ISSUED -713 b O AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE-�� <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# T31"A-f­ <br /> PE CODES FEE INFO AMT REMITTED CHECK# BY DATE PERMIT/SERVICE# INVOICE <br /> �I i-5 c,'� SR#� <br /> (`_F7 IIJt, _1A/AIVFR f:A7 I FTTFR nP Al ITHnPl7ATinN TO CIr,NP RAAIT FNC`PnAra-IAAFNT rlrlr. <br />