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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 />6a a <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 <br />'HealthDepartment. <br />Assessors <br />= 5 3 y 3 o I fWELL Location _Cross Street rS O City`iR�y Zipg5377 Parce# <br />G.4'�✓D /G G <br />PROPERTY y <br />O vnerS ✓tJ0!4Qt.l//✓ e ��"��J/'Address/8/O e ffA,2e-G %dam Ci XI <br />M&-F--OYZip ®pS-1-�0 <br />•&ne# '0 w— 3 tb! J�� <br />wD—=�Lt ci r• ✓/f/ a ® r /®fA7a l�/✓,C� Sew <br />v <br />C-57 Go tractor �A5/CC/W<fAddress /� H�t� �A City Zip Lic# Phone <br />i ArEe✓/.Q'c- i.�S. 2 '. a 6 <br />Consultant/ 8r&CMr's,�/,fl`✓ Y/'�'dAddress ^W �t/Rt CMrc Lic# Phone C -f 7 <br />GIS Coordinates: X 'Y Township 3 .��'t Range S Section IX' <br />WORK TO BE PERFORMED: <br />BORING CPT, GEOPROBE, HYDROPUNCH_ , HAND -AUGER, OTHER*) ® DESTRUCTION (choose type below) <br />® SOIL BORING # P,,� _ 0 OVER -BORE. DIAMETER <br />WELL # a PRESSURE GROUT <br />® *Other ^ GROUT SPECIFICATIONS <br />i <br />COMMENTS: <br />4-:J <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />® MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE ® MULTIPLE CASINGS ® MULTI-LEVEL WELL CASING DIA: <br />® EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC o OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL •%S TREMIE TYPE TO BE USED: AUGERS HOS <br />® AIR SPARGE/ OZONE ® PUSH POINT (GP or CPT)GROUT SEAL PUMPED:Yes o No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />OIL BORING ® HAND AUGER GROUT SPECIFICATIONS NfrA'f 4OWW"' <br />® OTHER: a OTHER APPROX. BORING DEPTH 7_4L' BOLTED TRAFFIC BOX or o STOVE PIPE <br />(if Y S, list specifications in comment section <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 andd�Regulatio d all applicable California State Laws. _ <br />Signed xx �� e��6 // e Title/CompanySE�/ E/✓(/N�G�ie " /p%�A ..i�t/ <br />Print NameD <br />/ <br />ate O �! <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By � Date Issued d/� / Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS/CO <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />7/ <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 />