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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />M! T I GAT O <br />UNIT IV <br />ORIGINAL <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 />WELL Location /� - / Assessor's <br />�� I W i�ci,�.Yt u Pla 4 - Cross Street11 ^^'' br. City Zip � `s7rp Parcel# 2-n -� - 2 fo <br />PROPERTY Owner m6idpt 00V -5akl Address01 -C 4, /City / ]:PAC Zip 3%6 Phone# ��� D3Sb1I Q <br />C-57 Contractor VU e0EW Address�7 �Ia FL'c City,-tiktkkn Zip �Zl�-Lic#&Z 4,%%G1�(� <br />Consultant / Sub CntrA 6&'," ad 66 6 -� Address637�'5hai.0 )U Cifi1_-,4Xk�r Lic#66022 7 Phone#"=0`-006 <br />GIS Coordinates: X , Y <br />Township Range Section <br />WORK TO BE PER MED: <br />EW WELL / ORING i CPT, EO ROB , HYDRO P NCH, AND-AUGE OTHER*) Q DESTRUCTION (choose type below) <br />,, \\ SOI BORING # L� OVER -BORE <br />0 WELL # PRESSURE GROUT <br />*Other:_ Grout Specifications:_ <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMERIDRIVEN <br />I7 VAPOR 11 MUD ROTARY <br />0 AIR SPARGE / Ozone PUSH POINT <br />SOIL BORING HAND AUGER <br />/0 \OTHER: OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLEoG MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA:�,1 W <br />CASING THICKNESSTh TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: All <br />DEPTH OF GROUT SEAL _ TREMIE TYPE TO BE USED: 0 AUGERS WHOSE <br />GROUT SEAL PUMPED: 0 Yes /0>N�o INOTE: MAXIMUM yFREE-FALL DEPTH IS 3C,') <br />GROUT SPECIFICATIONS: L�Pi%7 LlsLfh'� Liu �- d <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <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 />Count rdinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x ]� Title/Company} I S� AA u,4�,Cr 6 (.E'c <br />Print Name <br />L 1- A-L:VM. <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 10:4 W J3 e ve r- a C' � I !'d 6&4 <br />WORK PLAN DATED: -2000 <br />Application Accepted By + i - Date Issued lc 3 Area -14.5' <br />4S <br />Grout Inspection By Date 41 A Final Inspection Bye/-� ate �s <br />Destruction Inspection By Date <br />COMMENTS/ CONDITIONS: 5 5 Z <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT /SERVICE REQUEST # INVOICE <br />So <br />g9.o�9�0 <br />JbG�Lg <br />CS vo3� c z <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encronc ment oc 8/29/02 <br />