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1 <br /> San Joaquin Counter <br /> %� Environmental Health Department `� ; _,. S)TF ; <br /> 304 East Weber Avenue,3rd Floor,Stockton, CA 95202 MITIGA`It' QIP <br /> �" 7 (209)468-3449 Fax (209)468-3433 Web w�v�v sagov arg/ehd UNIT <br /> ' `. 04 DEC 3 3 FIV <br /> Well 'Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> application is Hereby made to San Joaqum County for a permit to construct and/or install the work described Tl - pplication is made in compliance with San <br /> .,oaquin County Deve p T e,Chapter 1115 and the Standards of San Joaquin County Environmental Health Department <br /> a "~l �T Assessors <br /> 'WELL Location o n �1 Cross Street, C+ Crly Zip Q52� Parcel#� 2(�(� <br /> PROPERTY • ` <br /> Owner. M`-i�ri���� +��L� Addresses ly St- City . ^21p_q5LL�,_Phone# CZ G- zc[o <br /> 'C-57 Contractor 4141)11 c.jr.,[. Address 0 <br /> Consultant/Sub Cntr QT F_ Address 7 1 �&, k •—City -c n Lich(.51 2211 <br /> Coordinates X Y Township Range Section <br /> ,61S <br /> WORK TO 0E PERFORMED <br /> p NEW WELL/ECRING (CPT,GEOPROBE HYDROPUNCH HAND AUGER OTHER`) PESTRiJCTION (choose type below) <br /> 0 SOIL BORING# OVER-BORE DIAMETER <br /> ' 0 WELL# tJ PRESSURE GROUT <br /> 1]*Other GROUT SPECIFICATIONS ., T t s} <br /> COMMENTS <br /> 'TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SP5CIFICATIONS <br /> ',MONITORING D HOLLOW STELA DIA OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING CIA <br /> EXTRACTION 0 AIR HANIMER/DRIVEN CASING THICKNESS TYPE OF CASING p STEEL ,PVC 0 OT,E;:; <br /> OR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TC BE USED D AUGERS 3 HOSE <br /> 'OSPARGE/OZONE n PUSH POINT(GP or COT)GROUT SEAL PUMPED 0"es 1]No (NOTE MAXI:AL11A FREE-FALL..DEPTH IS-0') <br /> )IL BORING a HAND AUGER GROUT SPECIFICA CNS_ <br /> 0 OTHER It OTHER APPROX BORING DEPTH Q SCLTED TRAFFIC SOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES list specifications in comment section) <br /> COMMENTS <br /> Q <br /> ' <br /> NOTE OF SITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS � <br /> 48 WORKING HOURS NOTICE SEQUIRED FOR INSPECTIONS <br /> c <br /> ' hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all appiicanle California Stater Laws &__ <br /> Signed x, � _ _ Tdle/Company S4- -Phjoa,4 Ar - ISN <br /> dl <br /> 'Print Name- 'I 6 r. Date <br /> DEPARTMENT USE ONLY <br /> ,SITE MAP IN UNIT IV FILE, ADDRESS' <br /> WORK PLAN DATED' <br /> Application Accepted By Date Issued / 0 ' Area2_ <br /> Grout Inspecbon 9 Dais Final inspection By Date <br /> Destruction Inspecban By Date <br /> COMMENTS/CONDITIONS La ZZ l —LLS T <br /> ACCOUNTING ONLY AID# FAC# <br /> ,OD>=S FEE INFO AMOUNT REMITTED CHECK# REC'D 13Y DATE PERMIT I SERVICE REQUEST# INVOICE <br /> G0 ,94 6z o 12,1161061 SR#0ogogor <br /> G57— WC_-WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> F11D 29-02-001 <br /> 5/22104 <br />