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WELLOERMIT APPLICATION N(hP r - <br /> SAN JOAQUIN COUNTY V MIT GATION <br /> ENVIRONMENTAL HEALTH DEPARTMENt"j 2005 UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, %,�(202 <br /> (209) 468-3449 PERM111SERTHEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED CES <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, 1C1�h__a��pter 9-1116.3 and the Standards of San Joaquin County Environmental Health Department. <br /> JIbUIGIPA r1t' NOX1r/Ityl IG55 {�A rp^ Assessors <br /> WELL Location Cross Street �-J(J1/ City latLu _ _ Zip Parcel# hy� <br /> PROPERTY5, t^ 11 II1 �AI __ �(,�� -J �d �n p <br /> Owner SL tp )SID E 447,ellort �tyC, ty�SLj VY\ — p 15 1 phone# 2w����00`�rJ� <br /> L' U Address 1{77 Ci Zi <br /> C-57 Contractor CC+y II +f--ri li I4 Add r�essyy,,,�,r'0% 69X 3349 City-y�'0 VI Zip�Lic#70GU Phone#707374/ <br /> Consultant/Sub CntrJt/W�5 Cy1ViPonrWntA�l�'Kddress � ��� OityS �R� c# RyoBZphone# Sd0-/o1&rZ <br /> GIS Coordinates:X - ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING^,CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') O DESTRUCTION (choose type below) <br /> 0 SOIL BORING# //1 UI`ZO 0 OVER-BORE. <br /> DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT <br /> SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING ''HOLLOW STEM DIA.OF BOREHOLE0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 7 <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS5dA.t{0 p--TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> EA <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SL &&Cf O y TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Wes 0 No (NOTE: MAXIMUM FREE-FALL ADEPT IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ARJ tArr L vt-1 4ii K4� a i 7 p0q&LA G <br /> 0 OTHER: R OTHER APPROX.BORING DEPTH-1 1,5 f O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 110 (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, Rulessc and Regulations, and all applicable California State Laws. <br /> Signed x(�� - Title/Company TitFS� �DODGIN-�;n J7,Q�(J i�JL GU vIC <br /> Print Name CoA1LiwIL E W60nWht2n Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 25775 S. T1& jerSOyA ?a-ss Ind. <br /> WORK PLAN DATED: <br /> 1 <br /> A � n <br /> Application Accepted By /V VG( !w �lrt e h Date Issued � 8 Y[C(yN.h(s^ 0 S Area PIS 3 <br /> Grout Inspection By Date Final Inspection By <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# S R V' 06q5138 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 'Vo I /1j �r9 9/a/ eA". ///1y or <br />