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` WELL PWMIT APPLICQTI_IN-MR&I <br /> Post-it'Fax Note —7671 Date #of � <br /> SAN JOAQUIN COU . T4 - From pages <br /> ENVIRONMENTAL HEALTH DEF <br /> 304 E. Weber, Third Floor, Stoc Co.lDept. — Co. L( <br /> (209) 468-344! Phone# 1� 0 Phone# l <br /> Fax# <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YE Fax# <br /> f <br /> application is hereby made to San Joaquin County for a permit to construct and/or install t1i <br /> Joaquin County Development Tittle,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Uepartment. <br /> NELL Location �l 1��T Cross Street Q�� A s <br /> ''""""���� Zip 952b� Parcecel#l# <br /> PROPERTY Ownerex/ f ,,r Address 3 /yr� (� b Zp I--�"5 Phone# 9� p3 7 <br /> :-,7 Contractor I� 5t ess C37�_W K DCity �Z�pkaL_Li �-Whone# 51b 1w6 <br /> ;onsultant/Sub Contractor — Address City Lic# Phone# . <br /> r 31S Coordinates:X Y Township Range % Section <br /> r MORK TO BE PERFORMED: <br /> EW"WELL BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") f ► 0 DESTRUCTION(choose type below) <br /> 0�801L BORING# _ D OVER-BORE <br /> j]WELL# D PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> 30MMENTS: A <br /> rYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ]MONITORING D HOLLOW STEM DIA.OF BOREHOLE In MULTIPLE CASINGS?0 YES W10 'WELL CASING DIA: .A/A <br /> ]EXTRACTION D AIR HAMMERIDRIVEN "CASING THICKNESS AIA-1 TYPE OF CASING: D STEEL . D PVC D'OTHER: <br /> ]VAPOR D MUD ROTARY DEPTH OF GROUT SEALS TREMIE TYPE TO BE USED: []AUGERS D HOSE <br /> ]AIR SPARGE RUSH POINT GROUT SEAL PUMPED: D Yes o (N TE: "XIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING D HAND AUGER GROUT SPECIFICATIONS: p� <br /> ]OTHER: II OTHER APPROX.BORING DEPTH r n BOLTED TRAFFIC BOX or D STOVE PIPE <br /> ' CONDUCTOR CASING PROPOSED? A�A (if YEs,list specifications here): <br /> COMMENTS: J!_j <br /> NOTE: 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 /> .'ounty Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x._cf ' _ Title/Company zev/ G' <br /> Drint Namur r _ jG�`]7Q� Date <br /> DEPARTMENT USE ONLY <br /> 317E MAP IN UNIT IV FILE, ADDRESS: �I �. SdV--1__ <br /> NORK PLAN DATED: 1q T t9? <br /> kpplication Accepted By �-�( 7 0 w to Issued C_ Area <br /> 3rout Inspection By V V Date Final Inspection By Date <br />` )estruction Inspection By. Date <br /> :OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY, AID# <br /> r e rfe <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R.EC'9,By DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SSD9 . o1 Zfa SR# 3 o <br /> 57_,_._ WC -WAIVER C-57 Letter of Auth7foko sign permit_Encroachment doc 1/25/02 <br /> i <br /> x - p <br />