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WELAERMIT APPLICATIONu1v/ E2TE <br /> SAN JOAQUIN COUNTY ITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENTa ) 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 VQI[�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 /> n�jol PC, <br /> L� 0a „I l- „ Assessors <br /> WELL Location of 49 q X0'11 Pon Street -1- � gD City QG Cf 2Zip Parcel# <br /> PROPEg7Y "jjI t0jeo U;rllCA lkf-0 mli U/1 r c,.I � Zi IS2'J) Phone# <br /> Owner Address 1 Jnn pp 4.V�+%+"t I`t/t City `/��_ �p <br /> C-57 Contractor WW(A pill IA;Ad'd/ress r� UL`hC�3W / City io Vi Z�ip�,457LLiicc#jALjtPhone#'0-TIL-4.� <br /> Consultant/Sub Cntr Sl'/7Mu5 Vj rorwa44) �ddre 33y�WI&M I MC �i�SCih Lic# p"-'"� / ��hone# 530-%X'2061-7 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> W RK TO BE PERFORMED: <br /> NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING#iMIU/-1( M frJ_L1��'YI LrV'-1$� /1'lGv'-� 0 OVER-BORE. <br /> DIAMETER <br /> I)WELL If a PRESSURE GROUT <br /> 0*Other GROUT <br /> SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS /1 <br /> ONITORING HOLLOW STEM DIA.OF BOREHOLE/,0 MULTIPLE CASINGS H MULTI-LEVEL WELL CASING DIA: 7 <br /> 1]EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS I -N'1-V TYPE OF CASING: 0 STEEL >115VC 0 OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL_ _ _TREMIE TYPE TO BE USED: o AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: IYes 0 No (NOTE: MAXIMUM FRSE-F LL DEPTH IS 30') <br /> f <br /> Q SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /le�v{ cercir� k � P'1 W I)fCc b � � a"a�l <br /> A- <br /> 0 OTHER 0 OTHER APPROX.BORING DEPTH /05 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED n0 (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed "' rL �y-a►xX�--ems- Title/Company b.�tR7�wq--R,1� �2./s-L✓/✓G �r TIS . <br /> Print Name /^lam - Wd9d jo wf} a..) Daten,T' <br /> DEPARTMENT <br /> -USE <br /> �ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 257N 5- S• Cssuh �isS I�e�• 1 me <br /> WORK PLAN DATED: <br /> Application Accepted By /L/,v Date Issued (5$ Dee 655 Area �ysj <br /> Grout Inspection By Date Final Inspection By <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# SR 00 4513 9 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35of 4A k,) LT9 9/d 11 IK/OSS <br />