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WELL r'ERMIT APPLICATION RJ...M
<br />AQU1N COUNTY PUBLIC HEALTH SERVICES
<br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSLJD
<br />Application is hereby made to San Joaquin County for a permit to consuct 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 Public Health Services, Environmental Health Division.
<br />.., . Assessor's
<br />e- oc.. ,-,,,, , • i, . e_ .-, ....• _ 1 Parcel# WELL Location ;.:'/O o 1 c:dtn.1 S 21.44 17" Cross Street D. I 1 re.A114-1-,,-- City )( QI-ii- i 4+I%-4 Zip
<br />PROPERTY Owner 4;-AZy .Dil.-0/4 y Address PO SO( _....
<br />)
<br />(r.;--STS---
<br />.
<br />City(jrccei'...,./ Zip/2f5 Phone#
<br />C-57 Contracture! rC•i•leti- 11.41.4-titi4-- Address -5 - e S - 1kl4 7r Iiiii::: • City41/442/1,--- Zip (tYS 2-t=ticid:72‘/ 7 phoni.11)(L-26 5/ 3S-S3
<br />Consultant] Sub Contractor -iL.-ALL_Zi,L_ki,if,'A',J ,itu4.A..Address '',:i 3 1 14. -41,4ii...; ,7 ,•-) co-----xit;ci,74,/ ticit,/-Eri: 2 7 Ph o n e# Widgill 4"lia)6
<br />GIS Coordinates: X , Y , Township Range Section
<br />RK TO BE PERFORMED: ;0
<br />NEW WEiL(
<br />11 SOIL BORING # V
<br />BORING(( CPT, GEOPROBE, HYDROUN9H, HAND-AUGER, OTHER')
<br />L"
<br />El DESTRUCTION (choose type below)
<br />a OVER-BORE
<br />1111 WELL # IA LA-d - 4 a PRESSURE GROUT
<br />*Other ? - Ikokou4, 74,,z,,,,i, iii;cLi_ 1 i. - St., L. uticr._ Grout Specifications:
<br />COMMENTS:
<br />JAN 30 -FrT/IRONMENTAL HEALTH DIVISION (PHS-EHD)
<br />i
<br />I.E.30/ALT4HE. Weber, Third Floor, Stockton, CA., 95202
<br />ENVIRONMEff
<br />PERMIT/SERVICES
<br />(209) 468-3449 RIG1NAL
<br />SITE
<br />MMGATION
<br />UNIT IV
<br />CONSTRUCTION SPECIFICATIONS
<br />DIA. OF BOREHOLE'
<br />
<br />
<br />'7 " MULTIPLE CASINGS? a YES VtNO WELL CASING CIA: z.,..
<br />CASING THICKNESd-it ki , qt TYPE OF CASING: 0 STEEL frPVC BOTHER:
<br />DEPTH OF GROUT SEAL 55- i TREMIE TYPE TO BE USED: AUGERS a HOSE
<br />GROUT SEAL PUMPED: Xyes a No (NOTE: MAXIMUM FREE-ALL DEPTH IS 30')
<br />GROUT SPECIFICATIONS: R.„).-C.TUINO iyar: --L-f.a- Ci44"iel\I 1-
<br />APPROX BORING DEPTH <de,' /C-i; Iri3OLTED TRAFFIC BOX or 0 STOVE PIPE
<br />CONDUCTOR CASING PROPOSED? kit) (it YES, list specifications here):
<br />i,4_4_,/ L._ "Zr id ?fp . CA.I f 'c i t--- i3ci_.),A14- 'TO 1 00
<br />1
<br />TYPE OF WELL INSTALLATION TYPE
<br />'MONITORING 'RHOLLOW STEM
<br />0 EXTRACTION I} AIR HAMMER/DRIVEN
<br />VAPOR UMUD ROTARY
<br />- AIR SPARGE a PUSH POINT
<br />,KSOIL BORING 1:1 HAND AUGER
<br />0 OTHER: n OTHER
<br />COMMENTS: /WC r* 114,61kitiii.1-
<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 />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin
<br />County tar ina9Fe..5,z Rr_and Regulations, and all applicable California State Laws.
<br />Title/Company S-i-iev: F CriitLi74- is 7
<br />Print Name Cki..(/ t7) •
<br />DEPARTMENT USE ONLY
<br />SITE MAP IN UNIT IN/ FILE, ADDRESS: 2.--z5 .6—e:)
<br />WORK PLAN DATED: 742
<br />A
<br />Signed x
<br />Date CillPqe "2-
<br />krkaPli 411Altiti
<br /> Area
<br />Date Application Accepted By
<br />Grout Inspection By Date
<br />Destruction Inspection By Date
<br />COMMENTS / CONDMONS:
<br />Date Issued
<br />Final Inspection Inspection By
<br />ACCOUNTING ONLY: AID# F Ac# r sp c)/),9, 79 6`---'
<br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT-I SERVICE REQUEST # INVOICE
<br />g7- y $7 /4 Sf 426Y - / ,20--- SR#2 - . .
<br />C-57
<br />
<br />WC -WAIVER
<br /> C-57 Letter of Authorization to sign permit bcroachmeflT aoc_
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