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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 />Assessor's <br />Well Location &LI0 Mt}:„t�Q�� t��"1r=� Cross Street I`�t�atl� I � �� City LXAAA yy Zip '15'_3'_-30 Parcel #132-(}3C-�01 <br />Property <br />owner id2ym Its lhYLi` o2 s L i b 'tP'Ct' Address, S. 'Bid 1= t7 t€( City r Zip ' q Phone # <br />C-57 Contractor h;Mane,L_;tznntrut,t;tt�roey1.4��Address ti3-7 31)a - ctad City ,Qi .n Zip 1:5215 Lic#GNES"-I Phone <br />Consultant/Sub Cntr;r>u tjanm�j j'W& sl rw eicAAddress j Show City 34W.. r) Lic*j&jZ1 Phone 101-Aul— M) <br />GIS Coordinates: X <br />Y <br />Township Range Section <br />WORK TO BE PERFORMED: <br />AMT REMITTED <br />CHECK # RECV'D BY <br />NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) Q DESTRUCTION (CHOOSE TYPE BELOW) <br />SOIL BORING# 'Bl, <br />13,2, a_3 fj <br />[I OVER -BORE DIAMETER <br />[IWELL # <br />C <br />❑ PRESSURE GROUT <br />❑ *OTHER <br />GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING <br />❑ HOLLOW STEM <br />DIA. OF BOREHOLE 'f' ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />❑ EXTRACTION <br />❑ AIR HAMMERIDRIVEN <br />CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ VAPOR <br />❑ MUD ROTARY <br />DEPTH OF GROUT SEAL `�p TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br />❑ AIR SPARGEIOZONE <br />PUSH POINT (GP OR CPT) <br />GROUT SEAL PUMPED: ❑ Yes 54 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />19 SOIL BORING <br />❑ HAND AUGER <br />GROUT SPECIFICATIONS <br />❑ OTHER: <br />❑ OTHER: <br />APPROX. BORING DEPTH ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />COMMENTS: <br />CONDUCTOR CASING PROPOSED Of YES, list spedficatians In comment section) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />n mem �eii <br />I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, an applie I mia Laws. <br />Signed ( Title/Company � i'do Teal -P/9E Obi �1$'11��kl kl') <br />Print Name drii- HnIrt- f I <br />t <br />DEPARTMENT USE ONLY �1 <br />SITE MAP IN UNITtV FILE, ADDRESS: 60�t i p S S fR t� t Q , `4 �,v o p JAN 2 .9 2009 <br />WORK PLAN DATED: 0 (a ENVIRONMENT HEN�TH <br />APPLICATION ACCEPTED BY ~% P ao 6 0 DATE ISSUED PERMI I/SERVAQ <br />GROUT INSPECTION BY CLQ& D FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECTION BY DATE <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: <br />AID # FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # RECV'D BY <br />DATE <br />PERMIT/SERVICE # INVOICE <br />i <br />-57 WC <br />_1N�IVER <br />C <br />sR# a <br />-- <br />57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br />EHD 29-01 11/r,/o7 <br />ENCROACHMENT DOC <br />WELL PERMIT APP <br />