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Sari Joaquin County <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd UNIT lV <br /> Lig + Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 /> .n� <br /> Assessors <br /> WELL Location 40"t M-ACC fid��'9"Cross Street -7 O City ;�ft y Zip 95-x', Parcel# -2 <br /> PROPERT�i �ftl1�},NAI%���&<p E �y . EL% /ft/CS/rllZlllU`•9S3 QSp��6®'.1�b <br /> Owner <br /> PROPER?,, <br /> r� Address �a ��n� City Zip Phone# <br /> �9 PV/cu�j� f o 17 V�E,ep City'��r.,'•� �3s 16 s <br /> C-57 Contractor ddress pJ,j a <br /> Consultant/Sale-6ntr- �— R�Address�t1✓ �� Ci �/A7✓CO,�ic# 7 Phone# <br /> GIS Coordinates:X Y Township 3 /H Range 5 Section <br /> WORK TO BE PERFORMED: <br /> NvNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> 0 SOIL BORING# p OVER-BORE. DIAMETER I <br /> Il WELL# 0 PRESSURE GROUT <br /> 0*Other.' GROUT SPECIFIC TIONS <br /> COMMENTS: .�rK v /r e�✓ G �' F/ �✓ Morai�i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE,_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: j <br /> ®EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS.0" fO TYPE OF CASING: 0 STEEL VC 0 OTHER: i <br /> S� <br /> a VAPOR ®MUD ROTARY DEPTH OF GROUT SEALS 0 fTr <br /> REMIE TYPE TO BE USED: ®AUGERS a HOSE � <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:9Yes 0 No (NOTE:MAXIMUM FR E-F LL_DEPTH_IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS / T �/�/�E s <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH .0'•S FT 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) ? <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> r <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 Ordinances, Rules a Regulations,and all applicable California State Laws. 1 <br /> Signed �'/! ,o ®�r Title/c n,part7 <br /> Print Name .w I'Vi/el-1A e'G eleprIf4fa Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: j <br /> WORK PLAN DATED: <br /> �/` <br /> Application Accepted By /� ^ / '�'a Date Issued o Area <br /> Grout Inspection By P Date ��27 ®7 Final Inspection By t' to <br /> Destruction Inspection By Date I <br /> COMMENTS/CONDITIONS: ��� / / <br /> ACCOUNTING ONLY: AID# FAC# <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 4 <br /> SR# L4® <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD29-02-001 WEB <br /> 9/11/2007 <br /> i <br /> I <br />