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WELOERMIT APPLICATION � V EISITE <br /> SAN JOAQUIN COUNTY -MITIGATION <br /> HEALTH DEPARTMENT ) 4 2005 UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 0 <br /> (209) 468-3449 ENVIRONMENT HEA TH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT�IS JU SEWICES <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 /> al_lo {� I,IQ„ PAM nl -P Assessors <br /> WELL Location IP 10 1 grrv� _Cross Street -1--W Ci <br /> tyq �pZip Parcel# <br /> OwOerE C�QO vitlfq IfuS{ IN W dol I`EA City�i—ZiP 15731 Phone# <br /> Address_ J tO Yt p <br /> C-57 Contractor f i Ii Address/°iO i 0mr 7 Jb n—City io I/' Zip P571 Liic-#710D7`I Phone#—L-7 4-41 50 <br /> Consultant/Sub CntrS" F,ui roof �kAddresl3O�WI�ipyI MSU(. IJi Cit Li p'"'", <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> U SOIL BORING# /24U/�I�T IA/--I1 rN 1p/_r$� �(�rmay D OVER-BORE. <br /> DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> p`Other GROUT <br /> SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING HOLLOW STEM DIA.OF BOREHOLE U MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: 7 <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS54A TYPE OF CASING: 0 STEEL >0VC 0 OTHER: <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_TREMIE TYPE TO BE USED: U AUGERS 0 HOSE <br /> U AIR SPARGE1 OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM F11RETE-FALL DEPTH IS 30') <br /> 0 SOIL BORING U HAND AUGER GROUT SPECIFICATIONS 1�(6MtNdg lid of Wi xto-�4 y,&44 Do" <br /> 0 OTHER:_a OTHER APPROX.BORING DEPTH kx U BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED no (if YES,list specifications in comment 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 prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> ,per <br /> Signed>��cl�-� L- W Tifle/Company]LK W0VPw�t 1)2/1-LVA16 <br /> Print Name CO'r!C/iJ` Fs' t,�,JOAptu>F} 2.p ,I Date 6r S &-r"' <br /> DEPARTMENT USE ONLY T <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 25775' S• ?AN[trs(1ll P4S5 RA I racy <br /> WORK PLAN DATED: T1 <br /> Application Accepted By 44el 10&&)'erro.t Date Issued 68 Dee 165 Area /Y5",3 <br /> Grout Inspection By Date Final Inspection By <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# - 5R 00 x{-5139 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350/ 4-tty 89 9/67 <br />