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San Joaquin County <br /> Environmental Health Departm� , . SITE <br /> 304 East'yVeber Avenue, 3rd Floor. Stockton, CA 95202 MITIGATION <br /> 4Y UNIT IV <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.sjoov.o e(id � �$ <br /> WellHEALIff- <br /> Permit Application FNV O <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS lk�' <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 Sari <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> A 57 0( i Assess o <br /> Frs <br /> WELL Location lU I tn1 C�1 v �` I mo_ --Cross Street S resno Agf- City " Zip i5�OL Parcel# <br /> ('44 POROP EP ;�" dress 1 5r r,(Ikr, Zip YS�0(a Phone# H <br /> i� t7��r Lic#72,1104 Phone# 904600 <br /> C-57 Contractor]%W i'�6\jjn[ Address t�� �o)C q,7© City Gar Zip <br /> Consultant/Sub Cntr r11;LMA 2PTQ nr ry9rS Address )71 1 M�r� S Cityf � Lic#Pb Aqfq Phone# <br /> GIS Coordinates:X {�5 Y --121•3 Township Range Section <br /> IW RK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> I(SOIL BORING# 58-4 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROU CIFICATIONS <br /> COMMENTS: ✓ -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING FT-IOLLOW STEM DIA.OF BOREHOLE 6' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ______ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> HOSE <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1 TREMIE TYPE TO BE USED: 0 AUGERS <br /> ?, <br /> 0 AIR SPARGE,'OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 111,11%s 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> rSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH � / 0 BOLTED TRAP=FIC 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 /> 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 Ordinan ules and Regulations, and all applicable California State Laws. <br /> Signed x , Title/Company Ge-oIil3rA�5 Date-3 <br /> Print Name Da <br /> LCe L� !�C� 3 /31 /C)6 <br /> — <br /> DEPARTMENT IJS- ONLY 1Z" -3.5. Z(o <br /> SITE MAP IN UNIT IV FILE,ADDRESS: J -1 Z" IVOIIJ L� <br /> WORK PLAN DATED: A 7- 67 <br /> Application Accepted By Date Issued Area 6F� <br /> Grout Inspection By NDate Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAc# <br /> PECODE FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-5 _ _ W —WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> 1 !11) u <br />