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WELAERMIT APPLICATION <br /> SAN JOAQUIN COUNTY ��((�ITE <br /> ENVIRONMENTAL HEALTH DEPARTMENIV�{I 2005 UNIT IVTION <br /> 304 E. Weber, Third Floor, Stockton, p 8g5202 2005 UNIT IV <br /> 209 468-3449 ��HCNMENTNE <br /> PERMIT/SERVICEST H <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 /> �` I (� 1�_, /� � I ^{� Assessors <br /> WELL Location I Q A tN 'd"0.?��e4im R5S {W Cro's1s Street T-!S>o City nc�c Zip -�n Parcel#-3 -7 PROPERTYC /. / .1 ��l() E I7A�I "�^. Cit k{ JZi IS I Phone# dpl-449 �J3 7-7 <br /> Owner -J o C t0V✓tM. Address 11''1� qq 99 Y P� <br /> C-57 Contractor OC ri �islic Adldr'esss POS IABX 3.510 City io Ul k Zipg4571 Lic93& Phone#7�7-37H-S�3�o <br /> <11 �' 'r^ > 'fiddres.�'l LaM.e.Nt "< 0,, T t 5y (o 1.0kt g5�4ZPhone# <br /> Consultant/Sub Cntr.St/✓-1, .S �utvl „i rvti J <br /> GIS Coordinates:X _ ,Y ,Township Range Section <br /> W RK TO BE PERFORMED: <br /> NEW WELL I BORING q,� j,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# (•'/I(.1�'Zd 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 /> N�WCNITORING �iOLLOW STEM DIA.OF BOREHOLE, []MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 9 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS5Cti-LID TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL p <br /> C1 O y TREMIE TYPE TO BE USED: $,AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: XYes^ '0 No (NOTE: 1M1''��AXIMUM FREE-FALL IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ARJ (O1+^ZJ 1 W s M� C O+C1:� <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 115 e 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 egulations, and all applicable California State Laws. <br /> Signed x � - -- -c- oQ-- Title/Company�K S� �QO�GIiF>eA XW1L/•/wJe 1=Q <br /> Print Name GOA.-/A/G E Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 25775 S. Tllr4erSoN Fats Tat. <br /> WORK PLAN DATED:^ r <br /> Application Accepted By /V VG( Date Issued 8 Dece"bCP '05 Area i YS3 <br /> Grout Inspection By Date Final Inspection By <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: p <br /> ACCOUNTING ONLY: AID# FAC# S R 5 138 <br /> ICE REQUEST# INVOICE <br /> PE CODES FEE INFO I AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERV <br /> �9 <br />