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*an Joaquin County <br />Environmental Health Department <br />600 East Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <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 />'� q .�S3y3oi <br />WELL Location C!lRR�4`L ��`�✓ � _Cross Street � S�y City �R�% _zip99377 5377 Parcel# Assessors <br />�,q-�►/p Fie L <br />PROPERTY / Zip �S�Jq <br />�6 fownerQGUttr✓Zddress/SIO E��.d'lfhone# %20� 3 <br />✓�J/ ® WAW i l-va 1fx-S.S-S �fS/LS- ,til <br />C-57 ContractorRE 4,9/C�//�Address g� f�N✓� �'/� City _ Zip Lic# Phone <br />Consultant / Sub-Cttt1' SF/f!i✓ Ei✓✓i'ed� Ades, �fl1e/ CHYC ty Lic# Phone 9J -S 2-9 <br />¢ / <br />GIS Coordinates: X 'Y , Township 3 S� Range S Section /X - <br />WORK TO BE PEV4LM6 <br />BORT ,�C�PT,, GEOPROBE, HYD' UNCH HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL G # —_ _ a OVER -BORE. DIAMETER <br />0 WELL # ' <br />a PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMM <br />TYPE OF WELL J INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />® MONITORING HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: — <br />® EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER:/� <br />® VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL %S �TREMIE TYPE TO BE USED: 0 AUGERS 0 HOS <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: XYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />lifbOlL BORING 0 HAND AUGER GROUT SPECIFICATIONS A14r*f 600'W"" <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH f 0 BQLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR ASING P <br />Sr 714o/ E <br />(if Y S, list specifications in comment section <br />®IA"ICr faY�l�/Cl O✓C /�� L"n <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 Ordinances, Rules and Regulatio d all applicable California State Laws. _ <br />fX <br />Signedx l/C// ®'® Title/CompanySEAl/A/ Ei✓f/NEE/e—%�L✓%� " .j��Lf� G�'� <br />Print Name Date 47 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By ) �®® Date Issued __Area <br />Grout Inspection By P ate ///f-711 7 Final Inspection By A/ ate <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />q'71 <br />SR# <br />C-57 WC --WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-601 WEB <br />9/11/2007 <br />