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-01/25/2905 15 53 2094683433 FIFTH FLOOR PAGE 02 <br /> Sang Joaquin County F EMVEU <br /> 10 <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95242 JAN - 7 MkilTIGATION <br /> (209)468-3449 Fax (209) 468-3433 Web www sjgov Or <br /> N ROkVMEiVT HEALAINIT IV <br /> Well Permit Application PERMfT/SERVICES <br /> NON-REFUNDAsu PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a pormit to tunatruct and/or Install the work desenbed Thrs application is made in oompllanoe with San <br /> Joaquin County Qevelopment Title Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> &4.-,+ 2n ktu» "j c-ec-t- 7YWk514 ,"r, arra.OrA C s,.a i Assessors <br /> WELL Location -ilio f( i Crass Street..&I rid _City 3�6khjv _ZIP oo) <br /> PROPERTY <br /> Owner F'a + 114 pq>^Address 1 2?04J W 114 o, S>` City-51h+cl'-4an zrp°T_ 1 Phone# <br /> C-67 Contractor A `11+- Address "` City. zip, -= LtcAk= Phoneft Consultant!Sub Cntr VK , Address 3 00 C,I�lq.7L' City Co`�L!c#_ phone# gf6 8�1-0`!Op <br /> GIS Coordinates X Y _ Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL!BORING (CITr GEOPROSE,HYDROPUN H HAND-AUG OTHF-R') a DESTRUCTION (choose type below) <br /> SOIL BORING*I At t; ;2A-e- ��¢- <br /> (I OVER-BORE DIAMET<:R <br /> a WELL# - <br /> a'Other a PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS <br /> =kor Wirt-L INSTALLATION TYPE CONSTRUCTION SPECIl;lrATIONs <br /> El MONITORING U HOLLOW STEM DIA OF BOREHOLE a MULTIPLE CASINGS b MULTI-LEVEL WELL.CASING DIA <br /> a EXTRACTION Q AIR HAMMER1DRivEN CASING THICKNESS TYPE OF CA51NG d STEEL Q PVC Q OTHER <br /> it VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMtE TYPE TO BE USED a AUGERS a HOSE 44 <br /> ARGE!OZONE a PUSH POINT(GP or CPT)GROUT 51_AL.PUMPED a Yes Ei�Fla (NOTE. MAXIMUM FREE-FALL 13EPTH 1$30') <br /> OIL BORING IAND AUGER GROUT SPECIFICATIONS <br /> en RSPTHER- `a OTHER APPROX SORING DEPTH d 134LTE0 TRAFFIC 80X or Q STOVE FIFE <br /> CONDUCTOR CASING PROPOSEDe :5 �(It YES,fest specifications in cvmrnant section) <br /> COMMENTS �� �ar'. �-a rv�C ' #0 ct}11e - ru rourwa S� <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 x TitlelCompany:5+&f{ <br /> Pnnt Name Qate r Z(L3 c q <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS, c <br /> WORK PLAN DATED: ' <br /> ApplccaUon Accepted By—L Dale Issued_ �1 2-iL0 Areae <br /> Grout Inspectlon By Date T- �- <br /> Final Knbpecbon ny _ _Date <br /> Destruction Inspe�on By Date - <br /> COMMENTS 1 CONDITIONS I p <br /> ACCOUNTING ONLY AID# FAC# <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST 9 INVOICE <br /> 7S-q ,Ld <br /> -57 WC„_WAIVER T C-57 Letter of Authorization to sign pe.rrriit_Encroachment doc" <br /> r;HD 29-02 401 <br /> W22ro4 <br />