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WELL.ELL. '71 .MIT F P L I C A T I C"N R'`V"1 N r�,i4 Ydr�r <br /> AN JOAQUIN COUNTS �� ������+��� <br /> ENVIRONMENTAL HEALTH DEPAR a-MENT (EHD) UNIT IV <br />' <br /> 304 E. Weber, Third Floor, Stockton, CA , 95202 DWU <br /> (209) 463-3449 <br /> NON-REFUNDABLE PERNtrf EXPIRES i YEAR FROM DATE ISSUED <br /> tlllication is hereby made to San Joaquin County for a permit to construct and/er install the work described This application is made in compliancewdh San <br /> aquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Environmental HealthDepartment <br /> `- <br /> �}} RJ <br /> l T-t1fr �n& L' Lop, Zip 15a�Z Asse sot'S�SS^ 1��� ZG <br /> HELL Location l£]9 !y.-rj4a gNrj^t r-1�` Cross StreetCapj4pL�_City <br /> L_ ,& p ��x CG 3b Ciry Zip 95378 Phon � g�776�1 <br />�ROPERTY Owner, ry_�y �A�',a,�,r P�Ort t Address_,Gti, a <br /> 2-57 Contractor s� DR Jl' :%3a D0141C, Ci to City 11 <br /> �"'`r Zip 35792 Uc#W7s/Q Phone# 9/6 (a� <br /> �} ,�jj[�►',_ , t�� Address 1 S F} r <br /> consultant/SubCnir A ,G, Address 837 `5�'�'"' R� C,ty sT�c090Li� 8oad7 Phone#A� <br /> GIS Coordinates X ,Y Township N Range Section r 7 <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER OTHER`) q DESTRUCTION(choose type below) <br /> (I SOIL BORING# a OVER-BORE <br /> EL # MW-7.mwk . MW—9 - U PRESSURE GROUT <br /> #her � - Grout Specifications TaAA Q ypE <br /> - <br /> oMMENT: w�� wo ry ;3 " . . Ra,--a - - <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ,�IOLLOW STEM DIA OF BOREHOLE 1S" MULTIPLE CASINGS?)(MULTI-LEVEL?0 WELL CASING DIA <br /> EXTRACTION ©AIR HAMMER/DRIVEN CASING THICKNESS 5-qtr I '44 TYPE OF CASING a STEEL a PV9- LL <br /> o-r FR � /c, <br /> VAPOR 0 MUD ROTARY DEPTH OF GRCUT'SEAL,35 FE£+ TREMIE TYPE TO BE USEDGERS p HOSE <br /> PARGE/Ozone [I PUSH POINT GROUT SEAL PUMPED Yes [I No (NOTE MAXIMUM FREE- DEPTH IS 30') <br /> i BORING HAND AUGER GROUT SPECIFICATIONS &rT16,jO 7YE <br /> Q OTHER 11 OTHER APPROX BORING DEPTH)5 a F T �- BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> C-ONDUCTOR C I G PROPOSED7Ajo�_(if YES lieLciticatons here <br /> LOMMENTS S !7Ove WGR L\1 e 3v � D <br /> , D67 <br /> O <br /> NOTE <br /> OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> aunty Ordinances, Rules and Re Mations, and all applicable Californl tate Laws <br /> Signed x Title/Company JFC' T (�Ej:JZf5% <br />�rint Name�► A J. C u Z/fA Dated- 0-3— 943 <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE, ADDRESS: <br /> ORK PLAN DATED: •Z'J 0 <br /> pplication Accepted 8y Date Issued �r 03 Area b�8 <br /> rout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> OMMENTS 1 CONDITIONS <br /> NTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST#I INVOICE <br /> MW <br /> -57 WC -WAIVERC-57 Fetter of Authorization to sign permit Encroachment doc 8/29/02 <br />