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WELL*RMIT APPLICATION , <br /> SAN JOAQUIN COUNTYU <br /> ENVIRONMENTAL HEALTH DEPARTMENt ITIGATION <br /> 304 E. Weber, Third Floor, Stockton, pp g X005 UNIT IV <br /> (209) 468-3449 p��NMENT T/SHEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE S'SUEDRVICES <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 /> Assessors <br /> WELL Location5bb ft/ A Y0lG�nG5S <br /> N Cross Street City !/Lt�Zip Parcel# hlej <br /> PROPERTY // p '` `I r� - G Z' <br /> Owner 545) T e lC t V� Address I01V��7E 17gqq� 14A At City SlnCO , Zip S?01 Phone# ��-4r0�'y�-7 <br /> C-57 Contractor OC rn �i� IC Address Ro' 60-N 3349 City i00 Zipy $&Lic#70 Phone#70737y-�� <br /> SF X32 Park D,, Ci1#5w &It Pao' q%. 92 <br /> Consultant/Sub Cntr /6V _S eigUiron Wb ddres ty Lic# Phone# 530-674`a� <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> W RK TO BE PERFORMED: <br /> NEW WELL/BORINGCPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER ) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# i �`ZD <br /> DIAMETER 0 OVER-BORE. <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0'Other GROUT <br /> SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING V�AOLLOW STEM DIA.OF BOREHOLE []MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 9 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS5Cti. 41) p--TYPE OF CASING: 0 STEEL XIPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ��O y TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE [I PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Weps,, 10 No (NOTE: 1MAXIMUM FREE-FALL DEPT IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /IPaT C4v%tJJlDCK6:hac/ m <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 11,5 / 0 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 egulations, and all applicable California State Laws. <br /> Signed x (if � �- o�. Title/Company AQJ3� LI1"QpO4V*,en �]�iwiJL CO Xkk� <br /> Print Name C6A, /AJ6 E WboDwi4P Date <br /> DEPARTMENT USE ONLY ' <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 25775' S. T6AexG san P4Ss —ed, <br /> WORK PLAN DATED: �!� <br /> Application Accepted By NVGf 4a crJ 4 h Date Issued 0 8 DCLGl 0 5 Area <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 Ob Jf 5 136 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> o I /%1w k9 9/0/ elm. ////Y1ar <br />