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A 0 U ----C O U N T Y--- .51 If' a N a OGA MN V 'ELL 8. LBORA 36 u� IT ��p,Lj_ Cff NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 ;'2rrw's Advance kJotice. Required For All inspec i olls 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 Joaquin County Development Title.Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address _V_fl t f 5 • L4 -Af la o`-1 1t ro, l City/State/Zip 3�:%C t'_'#�:t l ,1 �'T Phone Cross Street L6-�-at. - u•[ "..)C'U) ' ,, ' !1PN Property Owner` ��. �1 S' Phone l - 71 e-i 4 Address t C-t J City/State/Zip -'{L�7 c r" C-57 Contractor t_"['t-f-(lr (r h�L`.I L�f1 € I �" 3 ho e 1 I,, License# �. tS�� - �--�Cam. C.' � C-/�' Phone Address __?�t�'C-` �x�Ci (jt .1ke+i f E��. 7(�� City/StatefZip tittles lc! �jrA_ 6A W. <. 2- Cons ultant/Sub-Contractor License#/ Phone Address City/StatelZip CONSTRUCTION WORK TO BE PERFORMED: *Nate: Offsite BoringsPAJelis Require Access Agreements or Encroachment Permits TYPE OF 1VELUBORING NLRIBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ t,toutroRING ❑ HOLLOW STEM BORING DEPTH _ t Q }- ❑BOLTED TRAFFIC BOY ❑STOVE PIPE ❑ EXTRACTION olapour%,ater) ❑ HAMMER/DRIVEN DIA OF BOREHOLE } ❑t.IULTI.RLE CASINGS❑MULTI-LEVEL V/ELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ILSOIL BORING PUSH POINT(GP/CPTI CONDUCTOR CASING ❑Yr-s ❑Na Bonr, Dia: g Casing Dapih:❑ INJECTION AtSPiro�.Olcro: �� g Casin Dia: t ❑ HAND AUGER GROUT SEAL DEPTH TRE1.11E TYPE TO BE L'SED: ❑AUGERS ❑HOSE ❑PIPE❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maxim. m Fre--tall Depth Is 30 Fl) WELL/SOIL BORING IOs 40 GROUT SPECIFIC TIOI iS 1 tSn• � DES04CION4779K TO BE PERFORMED: — + t �/ DESTRUCTION METHOD: (CHECK ALL TH AT APPLY) It WELLS TO BE DESTROYED ❑OVER-BORE DIM41ETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet beiovl surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to fee,,below surface TREI IIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑N-11,15Hg00i i CAP ❑3 feel below surface or feet belmY)Surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be dono in accordance with ,r� San joaquin-County Ordinance Codesand Standjkrds,and all other applicable California laws. Signed /G�-1�. T,. ��Af� i,! " �TillelCompan5'1g/Yf Print Name /\ Gr D,�'� /�f. r� w �/ Date aEP RTMENT USE ONLY Application Accepted By: L, �,1 ( i L - Date Issued: C) ' �r Grout Inspection By/Dates: Destruction By/Date Inspection B p y Facility/Site Information r FA Name �- J. iFA Address + / r Ian ,it�r �V�i "t stt Gt.{•s,��, FA>E C) t i�� (;�I�� P� �\ .•�- •� ' FA PE Z Mn Revie;�ed By 'P/ork Plan Date II C•57 ❑C-57 Aulhorizatien for Other to Sign Permit ❑t"Jorker's Comp ❑V/oeker's Comp Vvaiaer ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval fvIFR feol COMMENTS/CONDITIONS:", / / n � [�"r1CJW 1 l S } ( VVP TYPE 1 PE C t=EE INFO AMT REMITTED CHEGt{{{ RECV'DBYI DATE WELL PER(iAIT#F INVOICE# Permit 5256 x ' { �1 ) ,"L I S` ,a l L V (J v 4,.F J� . No 6" 'i 868 E. Hazellon /\venue J tocklon, California 95205 T 200 468-3420 F 209 464r- � r � 1 1 O'13S 1 wvl N.sjceftdlicn e:;o 2a.ot aa-za-�;t � / t� r I I ! L i Site r,liligariun 4Va11 Parn it Apr hcalicn L t 1