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r4 .� rd urrairva>Itt tau 11caltb De-partm� v_��Y __,1 SITE <br /> 404 L�oO V0 cbet Avelnau, Std flow. Stockton, CA 95202 � ; s M171GAIt0 <br /> (209)468-3449 Fax (204)463 3431 Web www .,Jgruv ox hh UNIT IV <br /> OR ` Well Permit Application <br /> 11;J�k , <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />)plication is hereby made to San Joagum County for a permit to construct andlor Install the work descnbed This applleation is made in comphar=With San <br /> agwn County Development Title,Chapter 0-1115 3 and the Standards of an Jaaqurn Cou ty Environmental Health Department, <br /> Y 11 ,,,,5 E5t�r a 1 r1N Assessors <br /> Ps <br /> f W. n e++) �O D� Zip �I S �/2. Percal# -d <br /> ILL.Location- r J�I �'.IY4�1� Cross Street,WAM�iJie ----CdY - <br />'ROPER ]�r9A.0 SRC <br /> rler i CrA�w& Alddress/lo j � • r1&'} 1(1 60)11 Cay t-901" <br /> -OD ZIP9 Y'_Phone# I'A .311 �3 3 <br /> R4►�;M9 957'yU0.1) !!69 <br /> 17 Contractor COSC E y V dr0=1r4L 4HfL. CrPL��_ city [oA�Sa.�f4 p 7 `lo Phone# �/f�` � <br /> nsultant 1 Sub Cntr A, mss_ - - _Address„ )2sWAt+�/ } ity_ T l [ Llc# Q Z g _Phone#Z ori - T' f o� <br /> Coordinates X Y Townshrp Range Sectiorr — <br /> vORKTO BE pEFiFORMED <br /> EW WELL 1 BORIN(3 (CPT GEOPR BE, _ ROPUNCH HAND-AUGER,OTHER") a DESTRUCTION (choose type below) <br /> OIL BORING# 13 OVER-SORE DIAMETE <br /> �LL# AA 'I G ROUPRET SPECIFICATIONS <br /> ONS_ <br /> SURE GROUT <br /> � Other �-- <br /> MMENTS SF F -UT S -5 -2 <br /> eL INSTALLATIOM TYPE CONSTRUCTION SPECIFICATIONS !r <br /> RING HOLLOW STEM 01A. OF BOREHOLE ULTIPLE CASINGS Il MULTI-LEVEL WELL CASING DIA <br /> TlON U AIR HAMMEFJ0R[VEN CASING THICKNESSee� TYPE OF CASING a STEEL A PVC D OTHER <br /> d VAPOR 6 MUD ROTARY DEPTH OF GROUT SEAL `f O r _TREMIE TYPE TO BE USED AUGERS [I HOSE <br /> SVGE!OZONE p PUSH FO:Wr(GP or CF�GROUT SEAL PUMPED K1 es n No (NOTE- MAXIMUM FREE-FALL DEPTH IS 30') <br /> OING a HAND AUGER GROUT SPECIFICATIONS o r'rr_ <br /> 0 OTHER Q OTHER APPROX BORING DEPTH r OLTIED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED IV a (if YES, list spe aficatrins in comment section? <br /> Lmr4iENT$ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS 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 Sart Joaquin <br /> ounty Ordinances, Ribes and Regulations,and ail applicable California State Laws. <br /> . <br /> Signed x TitlolCor>ip&ny I3; - <br /> 1E, <br /> rnt Name CV date l Q <br /> DEPARTMENT USE ONLY <br />�1TE MAP 1N UNIT IV FILE, ADDRESS-. <br /> 1IORK PLAN DATE0. <br /> Apphcatyon Aceept06 By_. _Date issued 1 C1�f fAli Area��� <br /> rout Inspection Sy Date Final lnspoobon By Date_ <br /> Restruction <br /> ate -- <br /> estructyon inspection By Date <br /> OMMENTS I C0NUI7I0N5 0 y L-W <br /> ACCOUNTING ONLY AID# FAC# ' <br /> DES FEE INFO 1 AMOUNT REMITTED CHECK ft RECO BY DATE PERMIT!SERVICE REQUR$T# INVOICE <br /> tejtt .7 SIS#Ayy�' <br /> C-57— WC___,-WAIVER,_, C-57 Letter of Authorization to sign permit Encroachment doc ........_. <br /> 29-R2-001 f <br />