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Signed
<br />Print Name
<br />Title/Company
<br />,
<br />/
<br /> Date 6 I
<br />hereby certify that I have prepare
<br />Regui lott“ramallt applicable C a Laws.
<br />pplicatIon and that the work will be done I accordance with San Joaquin County Ordinances, Rules and
<br />ACCOUNTING ONLY: AID* PAC #
<br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE * INVOICE
<br />7 /24 /CI SR#
<br /> C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC
<br />e
<br />C-57 WC -WAIVER
<br />. Jul. 16. 2008 11:57AM No. 2439 P. 2
<br />SAN JOAQUIN COUNTY
<br />ENVIRONMENTAL HEALTH DEPARTMENT
<br />600 East Main Street, Stockton, CA 95202-3029
<br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www siqov orci/ehd
<br />
<br />
<br />SITE
<br />MITIGATION
<br />UNIT IV
<br />
<br />WELL PERMIT APPLICATION
<br />Propert,
<br />Owner -\ Address 2;7_01 L.. City
<br /> Zip )kC Phone* (7.04
<br />- sCc ,
<br />C-67 Contractor \I J7 Address ri -I 0 City '• Zip 4 -i- Lie #Cc 4 -11 6 1 5 Phone
<br />+-
<br />Consultant/Sub Cntr C 17- S Address eC3c. '• City C Ce< ‘.• e A Lic# Phone
<br />els Coordinates X 61 cchr4
<br />WORK TO BE PERFORMED:
<br />NEW LLJBORING (CPT, GEOPROBE HYDROPLINCH HAND-AUGER, OTHERS)
<br />SOIL SQRING# L. - 2,e7- . 1-07
<br />$4-
<br />0 DESTRUCTION (CHOOSE TYPE BELOVV)
<br />El OVER-BORE DIAMETER
<br />PRESSURE GROUT
<br />GROUT SPECIFICATIONS
<br />
<br />"OTHER
<br />
<br />COMMENTS: - CO C.--I e---, r *-.4. ( r) c ,.., -(•-• of.--. 5 , 4--" D c., X t 1 ' L,.. 1 4. .11 ( ,5,,,,: {, q .0 r.,,, .i4' •-•-' f, A ,,, 4-01 /.. .c-, .• !. ..4- ,„,,,, ' -- A . ,.., \
<br />
<br />., . / P....-5 4.-4FLA L.:. .., c... d.„0, ,...... ,,,- ' -•• •-•) •,.
<br />TYPE F VvELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br />
<br />MONITORING XHOLLOW STEM DIA. OF BOREHOLE Si El' MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIAIS 1 r
<br />I=1 EXTRACTION CI AIR HAMMER/DRIVEN CASING THICKNESS <6 4 o--- TYPE oF CASING; Cl STEEL 4PVC ci OTHER
<br />El VAPOR III MUD ROTARY DEPTH OF GROUT SEAL ‘ .61. TREMIE TYPE TO BE USEE)'AUGERS I=1 HOSE
<br />El AIR SPARGE/OZONE El PUSH POINT (GP OR CPT) GROUT SEAL PUMPED: 0 Yes X No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30)
<br />VSOIL BORING 0 HAND AUGER GROUT SRECIFICATION a.-1- ( .e.._.,....,_,--\--
<br />0 OTHER: E OTHER; APPROX. BORING DEPTH p2- p - 0 ,"BOLTED TRAFFIC BOX OR 0 STOVE PIPE
<br />
<br />10,NDUCTOR cAISINCi PR9ROSED QT YES, iiat speciftions in carnmOnt igctlon)
<br />COMMT5:4 : k\ , l , ke-,., i ../ L., , 1 c - i-r -J 0 5 t.- ••• 5.., f, .. < b , i c r r'r^,ir.,. .." • r • 4-1_0-.4 .-;-.,,
<br />: . t
<br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS-
<br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS
<br />NON-REFUNDABLE PVRMI,T 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 Developm nt Title, chapter 9-1115.3 and the Standards cif San Joaquin County Environmental Health Department.
<br />V „ ASSessor's
<br />1 igr-4 akeet .k..f City g zip A, *7-% x2. parce l 3 --e:”z Wall Location"'
<br />-5 r'
<br />, Y-1'2-1 P c"" • Township Range Section
<br />DEPARTMENT USE ONLY
<br />ttv,. _ "A-D
<br /> FINAL INSPECTION BY laf
<br />SITE MAP IN UNIT IV FILE, ADDRESS: 0120 i f-•) •
<br />WORK PLAN DATED! -Q)'
<br />APPLICATION APPLICATION ACCEPTED BY DATEIStUED
<br />GROUT INSPECTION BY DATE
<br />DESTRUCTION INSPECTION BY , DATE
<br />
<br />/1
<br />COMMENTS/CONDMONS:
<br />
<br />Rua.)
<br />
<br />EHD 28-01 11151C7 WELL PERMIT APP
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