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Wan Joaquin County is <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/?IQL /t/t%1 Ldp/ '_ .�V y �;Oe4Gy p / S377 Parcel# Assessors <br />WELL Location Cross Street Cit / Zi <br />PROPERTY <br />✓�J <br />i ,K,�%E►T/i✓,CL i��S�.SO? .PtfS7 <br />3e0vAh'4dress//0 Gff4EC7^ Ci -0O nerN-4,F, <br />6-57 contractor 41 _G;0<(1 1AddressfS-of✓`X4 <br />City _Zip Lic# Phone <br />Consultant / serhfCTtR"'.i�Ffi9 /✓y/�� Address ��/ Cfl7� io Lic# Phone %%-� 2 <br />GIS Coordinates: X , Y®®, Township .� Range S Section—/X- <br />WORK TO BE PERFORM N'� <br />ORI CPT, GEO OBE, HYD NCH HAND -AUGER, OTHER*) Q DESTRUCTION (choose type below) <br />Q SOIL t?ttd # Q OVER -BORE. DIAMETER <br />Q WELL # Q PRESSURE GROUT <br />Q *Other GROUT SPECIFICATIONS <br />COMMENTS:�� So�� $�i� f Jia. )ne� c�G✓ >�� G'U'lle C74 S'`./y�e�•��roa+-�6✓ ✓ ,/oy �.1 <br />TYPE OF WELL KNTALLATION TYPE CONSTRUCTION SPECIFICATIONSQ MONITORING OLLOW STEM DIA. OF BOREHOLE( aMULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: _ �-EXTRACTION R HAMMER/DRIVEN CASING THICKNESS-- TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br />Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL '75 /r-7 TREMIE TYPE TO BE USED: Q AUGERS Q HOS <br />Q AIR SPARGE/ OZONE Q PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Yes Q No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />OIL BORING Q HAND AUGER GROUT SPECIFICATIONS 'Wer*( eeq'irw1 <br />Q OTHER: Q OTHER APPROX. BORING DEPTH FAQ B LTED TRAFFIC BOX or Q STOVE PIPE <br />CONDUCTOR ASING PROPOSED 6 (if YY S, list specifications in comment section <br />COMMENTS: le/i1 pn✓A� ��/+✓iit SC �/e a/ W /% e/s.a �I C✓ fG�Yl7 l<.f A/G /�� PrL <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 />Signed //y��/E Title/CompanySC'4L//'" �/✓y'�it/��/Q �PL✓'� ,j"d1�� G'i/ <br />Print Name /V - /0��f7`�E�' e,1W E°er?-d' Date -/a 4C <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By r Date Issued /// /0 ?, Area <br />Grout Inspection By �Date //1.291--0`% Final Inspection By , ate 4.2114 47 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: aywa !- <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />1/4'7/`-"' <br />9 / <br />SR# <br />C-57 WC -WAIVER <br />EHD 29-02-601 WEB <br />9/11/2007 <br />C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />