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WELLIRMIT APPLICATION <br /> SAN JOAQUIN COUNTY �(IIITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENTa ) 4 2005 UNIT N <br /> 304 E. Weber, Third Floor, Stockton, CA., 0 <br /> (209) 468-3449 ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT�Q� SERVICES <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 /> PA <br /> I- J241-Zip <br /> - Assessors <br /> WELL Location ab lob PA�ki5im-1P4116 Y�2 ._ICrross Street T-1510 City BC -Zip Parcel# <br /> Owner QTY CIAO V,CI`q ,Address 1(JI W_� &10y&vA 0 City j6U6 Zip j23 Phone# <br /> Owner �qpl`�')F_�'"�' /� /� ?7 <br /> C-57 Contractor W(X)d %Ili /0;Address&, B649C33b City to V; Zip 4S� Lic#Phone#707311/-y/,�?O <br /> Consultant/Sub Cntr J"S v1 r'C, �'Addres33C SV" 55 p ��6'Fz <br /> _ �� �iiHg2�vy �C 1), ary Phone# S30b761-�Z <br /> GIs Coordinates:X ,Y ,Township Range Section <br /> 'r <br /> RK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GIEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# � Mai-/1 0 OVER-BORE. <br /> DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'Other GROUT <br /> SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING HOLLOW STEM DIA. OF BOREHOLE//,,H MULTIPLE CASINGS H MULTI-LEVEL WELL CASING DIA: V <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS-45A W -7 TYPE OF CASING: 0 STEEL ')_�VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALR��TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 0 No 7TE�://M" AXIM 1U1''M FR E-F LL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS(2vgt t� 4.'i ry p I j/Noc4 z <br /> Douit <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH L05 0 BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED AD (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 /> Signed --d7t.cv� Lam. os-s .ta.�...�. Title/CompanyWong w+V-kiyr<_IA. /JG C'e 'r-w_ <br /> Print Name Cbr/G/.rJ6 !'- t.� 00,0 ctif� 2.p ' Date <br /> DEPARTMENT USE ONLY 7� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2S / IS S• !Rcilit"01 , ?4S5 Re), 1 r&cy <br /> WORK PLAN DATED: <br /> Application Accepted By 41�Cl _C -)CrSah Date Issued 68 Det 65 Area ),1/5 ? <br /> Grout Inspection By Date Final Inspection By <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: T 019 1- -0 <br /> ACCOUNTING ONLY: AID# FAC# SR oo�5 139 <br /> PE CODES FEE INFO I AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 7 <br /> 3501 44 t 0 R9 9/6, f/ 19 of <br />