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WELL ERMIT APPLICATION R M SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> pplscation is hereby made to San Joaquin County for a permit to construct andlor install the work described This application is made in compliance with San <br /> loaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> ELL Location 6914- L , Assessors <br /> - r� Cross Street City u Zip Z 0 2 Parcel# <br /> CROPERTY ! 1 <br /> Owner -��rti,` r- Address��! E1 [�r,1��J City 5 74c l7'o'� Z,pa5 ZuZPhone# <br /> tonsultant <br /> 57Contractor 1 Address .74 t Z, 4 t= L�.S[ ALC _City _ji�t t 1L1c#7�epj Phone# °.1 Z Z$yl/Sub Cntr AddressS"/ Ar Phon # 7 G 4 2-e Su <br /> t <br /> S Coordinates X Y �-�$ Section <br /> ORK TO BE PERFORMED _49 35 <br /> ,QNEW WELL / BORING (CPT 1t2�2zt`p'tI Ip CTION (choose type below) <br /> SOIL BORING# 095 r Y O DIAMETER <br /> ' d WELL# pN0 ROUT <br /> C � ��G�NEERINC' <br /> ID P11 E 1 �` <br /> sATEONS <br /> D01.lARS <br /> e ..- <br /> Ety�1ROPC ING� �N ��_' <br /> GON�6 6�23��P Q� <br /> P� �1A�KC��G 92705 <br /> SANZf� WELL CASING DfA <br /> t / <br /> pRoo OF ��N1 „� L PVC OTHER <br /> 4 F GA4�F O GA g16Ab 1J►'fpfl� --USED 0 AUGERS Q HOSE <br /> K O 5y eE'`" - ' , 0q .,r�XIMUM FREE-FALL DEPTH IS 30') <br /> N_ 1oN Uo p,IATA)t�0 G�� • <br /> y <br /> OTf U B599 <br /> yB sab BOX or a STOVE PIPE <br /> Gr _,%,.ANG PROPOSED (if YES, last specifications in comment section) <br /> OMML FOR _�Da4C� y1• <br /> NO � Z Z4 _ ACQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 1. 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 4herebyttrY that I have prepared this application and that the work will be done in accordance with Sart Joaquin <br /> ounty Ordinances, Rules and R ulatlons, and all applicable California State Laws <br /> igned x !L <br /> Title/Company lqG_) LJ <br /> Print Name / L-Cr.,Ivi /.r? it Daz,/,/" <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS B �+ Sje4La <br /> } <br /> IORK PLAN DATED' /�/ <br /> Application Accepted By Date issued /- 13-0 Area a, <br /> tout Inspection By Date Final Inspection By Date <br /> struction Inspection By Date <br /> COMMENTS!CONDITIONS <br /> VOD <br /> G ONLY AID# FAC# <br /> FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> SR# y- <br /> C-57 WC ✓ -WAIVER C-57 Leger of Authorization to sign permit Encroachment doc 9/30/02 <br />