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FILE COPY <br /> Ml San Joaquin Caunty, <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> • (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Permit P Well Pit Application /��j/�j/�'� <br /> ^C%FORA\ V/ / <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> pplication 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 /> oaquin County Development Title,Chapter 9-1115.3 and the Standard S n Joaquin County Environmental Health Department. <br /> Assessors <br /> NELL Location �»�l w �`�Q � ss Street `�S City �� Zip 9 Parcel# g'y� I <br /> PROPERTY �l 01 ,V e�rc.- Address ��"� W G�w � Lwcity Zip ` Phone# 66 <br /> Owner 'i Sa , e / y� <br /> C-57 ContractorE0,11 � �C Address 3 1 'r,,i;:� Palw�s�r. City Tos zpgsOp3uc# Phone# '31 6 6L- S /� <br /> Cn n o/ A-s toga S I C�r,f / <br /> Consultant/Sub CnV CI- • - Gam•-- Address �9Gq� 14e1 '►CitY�/"rw^TdwL1C# k �` Phone# <br /> —�--�$e rc es P k w j l S;c.u G <br /> GIS Coordinates:X <br /> Y ,Township 1 L Range Section <br /> WORK TO BE PERFORMED; <br /> NEW=lLBORING#_j <br /> L/ BORING (ro'r ^oo NvnPnPU CH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> f L 0OVER-BORE. DIAMETER <br /> t 0 PRESSURE GROUT <br /> goZ GROUT SPECIFICATIONS <br /> COMMENTS: ` <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE L" 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 /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Ndf, - h d e^' <br /> G BOLT9D TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: OTHER APPROX.BORING DEPTH D <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 hav prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Ru s a d Regulations, and all applicable California State Laws. <br /> Title/Company `A V 1 (JCS <br /> Signed x / <br /> Print Name 1 �� U.P r' f^i �l�t` Date l!�/ �'�c��f <br /> DEPARTMENT USE ONLY <br /> V' <br /> SITE MAP IN UNIT IV FILE, ADDR SS: g �l �'�Gt/GL2/3 <br /> WORK PLAN DATED: <br /> Area <br /> Application Accepted By <br /> Date Issued l0� 3 a�p <br /> Grout Inspection By <br /> Date Final Inspection By ate <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AIDFAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> o 3l'AA 2i <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encr doc <br /> FHn-)9-D'-01 <br />