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DWEL' 7ERMIT APPLICATION F RIAL SAN JOAQUIN COUNTY o <br /> (� 4 ENVIRONMENTAL. HEALTH DEPARTMENT EH ETF TN <br /> ( 1.1 IT 111 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95M 0 1 200 <br /> 4 <br /> . (209) 468-3449 ENVIRONMEN1 HEALTH � <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE MRKQT �U��F� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described This ap Uca ion Ade m compliancewith San <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> r <br /> i r Assessors N A <br /> A <br /> WELL Locatio Co _S-4 T-O-e_-r Cross Street �:! r � City 54c,_w., Zip Zo,$ Parcet# -- <br /> PROPERTY r rr <br /> OwnerAddrm'17-S n/, L( lma- o CrtyS -tc� ZEp SZa2 Phone# 2raQ -83Yq <br /> C-57 Contractor /��1,,;�C, Addressg5ca W� F.a� rr Cdy M� •� Zip S, Lic# o�Pho-ne/# <br /> Consultant/Sub Cntr_ _�r�,6�-,�l ^AddressZ�Q �ir-Ktr� S'4• Crtynor�Q Lac#R66�7 Phane#L -`/g50 <br /> GIs Coordinates X_ - Y Township Range Section <br /> WORK TO BE PERFORMED <br /> )kNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) n DESTRUCTION (choose type below) <br /> []SOIL BORING#S$-2c _� 58- 22- II OVER-BORE DIAMETER <br /> p WELL# g p PRESSURE GROUT <br /> 11"Other �• �h�� � GROUT SPECIFICATIONS <br /> COMMENTS •*r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [I MONITORING I]HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA <br /> EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS NIA TYPE OF CASING (]STEEL 11 PVC II OTHER <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL_„ f� J TREWE TYPE TO BE USED ]]AUGERS `KHOSE <br /> SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED )KYes I]No (NOTE: MAXIMUM! FREE-FALL DEPTH IS 34') <br /> OIL BORING (]HAND AUGER GROUT SPECIFICATIONS T>or-y f q.,C1 T+-,a.�"� <br /> 11 OTHER_ n OTHER APPROX BORING DEPTH /Sd 1]BOLTED TRAFFIC BOX or 11 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED IV.L-A (d YES,Inst specficatrons in comment section) <br /> COMMENTS C &f-r 5 Sp- Zn i,r-o <br /> NOTE: OFFSITE BO'RINGS REQUIRE ACC SS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 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. r <br /> Signed x 6--sir Title1Company-S0_-).0_r` -5-/Q`P-1^ <br /> Print Name t,-,M /� _ Date <br /> DEP/ARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �'7" 4!5- <br /> WORK PLAN DATED: ^p - <br /> y�c/ <br /> Application Accepted By Date Issued � Area ¢ <br /> Grout Inspection By pate Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AID# FAC# <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> sR do3sr 2Z <br /> C-57 W( ✓-WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9130/02 <br /> Lis �83o p� <br /> V <br />