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OPRIO <br /> Envi�SanJoaquin Coun ty304 East °erAv l Health D cIn <br /> U 4 <br /> (209)468-34 9eberAvenue,3rd Floor, Stoc�o rtment Fax:(209)468-3433 Web: CA 95202 <br /> Well Per www'Sigov.Org/ehd TION <br /> NDN- mit Application <br /> lY�q y 2 <br /> PPlication is hereby <br /> REunty, LE PERMITEXPIRESIYEARPROMOA7EISSUED o 20NIT iv <br /> Joaquin county made to San Joa E/1/I/fir` <br /> Development Title,Cha um County,for a permit to c WELL i/ry� ter 9-1115, and the onstruct and/or install the <br /> Location Id Standards of San J work descnbetl. I/E'i"'� /SFR alFA�rH Q/� <br /> PROPERTY °aquln County Environ This application is <br /> • Cross Street mental Health Department. <br /> mPliance <br /> Owner � ePartmenf. with San <br /> �. 7 '�7�i, �_C,ty * -Y Assessors <br /> C•57 Contractor . �, � Addressf T/✓U k /,,,. / —ZAP -37 <br /> -� vcC .4 Parcel# s/ _OiJ� <br /> _ _ 3 / <br /> Consultant/Sub Cntr �—Address (�(��;.� <br /> N ` 7v {�Z�Pneq <br /> City? .,rA• ' / <br /> GIS Coortlinates:X Address — Zip�ZN I Lic# <br /> `I-ic City Phone# ZJS=�� <br /> WORK 70 BE PERFORMED: �Lic# _ <br /> Y7 67Z <br /> q NEW WELL/ TOwnship Phone# <br /> BORING (CPT �Range L/� — <br /> s0r SOIL BORING# GEOPROBE, HYD —"�Section= <br /> e WELL# ROPUNCH,HAND-AUGER, <br /> 0*Other -I OTHER') <br /> O DESTRUCTION (choose type below) <br /> COMMENTS: O OVERRUCTION <br /> DIAMETER <br /> O PRESSURE GROUT — <br /> r1'PE— GROUT SPECIFICATIONS— <br /> MONITORING INSTALLATION TYPE <br /> — CONSTRUCTION SPECIFICATIONS <br /> EXTRACTIONHOLLOW STEM <br /> O AIR HAMMER/DRIVEN DIA.OF BOREHOLE « <br /> '{POR —�_ O MULTIPLE CASINGS <br /> O MUD ROTARY CASING THICKNESS YJ <br /> 2 SPARGE/OZONECIZ <br /> O MULTI-LEVEL WELL CASING DIA:�_"_ <br /> O PUSH POINT DEPTH OF GROUT SEAL TYPE OF CASING: _ <br /> L BORING (GP or CPT)GROUT S O STEEL PVC 0 OTHER: <br /> O HAND AUGER EAL PUMPED: TREMIE TYPE TO B <br /> _R.—O OTHER GROUT SPECIFICgFIONSIrYes 11 No (NOTE: MAXIMU E USED: 0 AUGERS <br /> — APPRO c'5+C-NT M FREE-FALL DEP iTHOSE <br /> X BORING DEPTH X6,v DEPTH IS 30') <br /> ITS: CONDUCTO A <br /> R CASING PROP—O BOLTED TRAFFIC C <br /> SED rNl l4 BOX or '1STOVEpipr <br /> E: OFFSITE B —�(f YES,list specifications in comment section) <br /> ORINGS REQUIRE ACCESS <br /> 48 WORKING HOURS AGREEMENT OR ENCROACHMENT PERMITS. <br /> Inances prepared this application and that the ECTIONS. <br /> Rules and Regulations, work will be done in accordance <br /> and all applicable California State Laws <br /> with San Joaquin <br /> Title/Company <br /> ZL7t- j Z.f -Zl)7� <br /> DEPARTMENT Date <br /> IT D FILE,ADDRESS: USE ONLY <br /> rED: mid <br /> ate lU Date Issued A_/Final Inspection Area W <br /> 0 i. Date <br /> .co Date _ �G ti <br /> o r AID# <br /> On o <br /> N S \MOUNT REMITTED FAC# <br /> CHECK# REC'D BY <br /> ■ ® �Q DATE PERMIT/SERVICE RE <br /> O t'� QUEST# INVOICE <br /> C-57 Letter SR# Q/ <br /> of Authorization to si f0 066 <br /> gn.perinit—Encroachment doc <br />