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WEL&PERMIT APPLICATION FLAM <br /> SAN JOAQUIN COUNTY FIME <br /> IMr <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Location.5,20 VW VAC0.f 0'jl C Lfl- Cross Street Vej City '� C(-K'VLY) Zip Parcel# • 2 • 10 <br /> PROPERTY Owner I�i�171 u1 j2!� Address -7(t) r rc�r- <br /> Ciky f� ip Phone# - 7(CC <br /> C-57 Contractor Address ci�Kb �.cxm4tA�- itY ZGtYV2--r � Zip�-Lic#ZY-332 Phone `� l (cCn� ���( <br /> coadoyrck <br /> Consultant/Sub Cntr !! ) 11"P'9Hress City RLi �Lic#los�14W53 Phone -Z <br /> GIS Coordinates:X Y "�-� _,Township 1 _Range_NPr Section <br /> APIA <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> p SOIL BORING# p OVER-BORE. DIAMETER <br /> WELL# MVq-11 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: 1-c C C ba, S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,MONITORING `gHOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: �4 <br /> D EXTRACTION a AIR HAMMER/DRIVEN CASING THiCKNESS<,1'J ed. :IQ.TYPE OF CASING: p STEEL ,$PVC D OTHER: <br /> d VAPOR a MUD ROTARY DEPTH OF GROUT SEAL k t TREMIE TYPE TO BE USED: jrAUGERS a HOSE <br /> p AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: $Yes 9 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING D HAND AUGER GROUT SPECIFICATIONS (V-'«+ (:C-rrC-- I'r <br /> p OTHER:_0 OTHER APPROX.BORING DEPTH '�D l `BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSE NJA (if YES,list specifications in comment section) <br /> COMMENTS: JAZUS Will M Sc r32,En(--dCLI21260AVx-,isAtk - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR EN ROACHMENT PERM/ S.�'�10� <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 TitlelCompany2U t 4 <br /> Print Name Date 1 2 I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3 2 0 2 We,-s+- 14 a m rrte r Lane, <br /> WORK PLAN DATED: SP s2+fbr ke-ir 13;* 2003 <br /> Application Accepted By r,Ia L Date Issued Al 0 t/e mbay' i e.1-004 Area r 4 5� <br /> Grout Inspection By Date 11ty® Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: Y 1 MW-11 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 35 1 9g.oD 89. v0 - -- SR# -'-1040406 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 9/30/02 <br />