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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.sjo
<br />SITE
<br />MITIGATION
<br />'illVFyN1T Iv
<br />TYPE OF WELL INSTALLATION TYPE
<br />IA MONITORING KHOLLOW STEM
<br />EXTRACTION 0 AIR HAMMER/DRIVEN
<br />VAPOR 0 MUD ROTARY
<br />0 AIR SPARGE/OZONE ,L PUSH POINT (GP OR CPT)
<br />SOIL BORING El HAND AUGER
<br />OTHER: ,1A I C rT El OTHER:
<br />CONDUCTOR CASING PROPOSED
<br />COMMENTS: tul,4 c\ c c-t-ist A-4-C
<br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS
<br />CONSTRUCTION SPECIFICATIONS
<br />DIA. OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:
<br />CASING THICKNESS TYPE OF CASING: 0 STEEL 1-,KE PVC 0 OTHER
<br />DEPTH OF GROUT SEAL 7- <-S TREMIE TYPE TO BE USED,E] AUGERS 0 HOSE
<br />GROUT SEAL PUMPED: 14 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30')
<br />GROUT SPECIFICATIONS k)
<br />3
<br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX OR LI STOVE PIPE
<br />(if YES, list specifications in comment pection) „ t cIA-
<br />WELL PERMIT APPLICATION
<br />MAY 2 8 2009
<br />Assessor's
<br />Well Location' 1L %, ---e,-.4 1,,- Cross Street \-- / 44 e kr-4-- City < Le, ‘.-4-c,---- Zip eN" to 7> Parcel #
<br />Property, . I
<br />Owner \ c-, c A- . 4- 0-v., it---1--.a— Address 1 7-0k ...) . ,..1...L.--11-._. City SA-bc ‘--1-.0-- Zip IVI.e,`", Phone #(-ta.4\q46 -avi-C
<br />
<br />-ftr...e- ..; 1,.....-- -•,,,,.... . k C-57 Contractor , Address -1-1‘ c v...)'• ye., " ....- City 1-oc t-4-.2.-- Lic # 4361 Phone (--LeDA)`1 4 S -17 rt-
<br />Consultant/Sub Cntr CF--1 coc ( Address tboo 1--t4'.u..-.., 4L,,,_ ‹, (c 31e3 City 3o€L-i• (.1--e-e I. Lic #S.'7111,-- Phone 14.-1 6c.L.I
<br />GIS Coordinates: X , Y , Township Range Section
<br />WORK TO BE PERFORMED:
<br />LII NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*)
<br />El SOIL BORING#
<br />
<br />E] WELL #
<br />
<br />*OTHER
<br />E DESTRUCTION (CHOOSE TYPE BELOVV)
<br />El OVER BORE DIAMETER
<br />['PRESSURE GROUT
<br />GROUT SPECIFICATIONS
<br />
<br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />ENVIRONMENT HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. ThisapidiKeilco7isdattEENFIITipliance with San
<br />e Joaquin County Development Title, cha ter 9-1115.,3 and the Standards of San Joaquin County Environmental Healtik gaipitirti+riEr v ILI ...„.1..÷
<br />3,a0 1 IA.) . Ira ON- V •
<br />COMMENTS6 C
<br />1
<br />4"-i 4-1A-4t-ss
<br />, e 1r C I Pk (=
<br />s's (A
<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 I accordance with San Joaquin County Ordinances, Rules and
<br />Regulations, and all applicable California Laws.
<br />.--"/
<br />C
<br />Print Name
<br />7 - ,..p•-• . I
<br />Title/Company 7‘-‘b i‘ -4,- A e:1 Signed \'`
<br />1 .5 //, ...N. , ____ Date C 1 VI ( r•-1
<br />DEPARTMENT USE ONLY g9.-b 6
<br />IAA'S —1.6%--- - 6...,..p,/ 126.....,. aktzt_.- Pre---os-2..7 toy- SITE MAP IN UNIT IV FILE, ADDRESS: 4:77-,;61
<br />WORK PLAN DATED: CU /2--1---1-} OCe it k —
<br />APPLICATION APPLICATION ACCEPTED BY
<br />GROUT INSPECTION BY
<br />
<br /> DATE ISSUED 6
<br />FINAL INSPECTION BY ?NO
<br />DATE
<br />
<br />AREA
<br />DATE
<br />
<br />DESTRUCTION INSPECTION BY
<br />
<br />COMMENTS/CONDITIONS:
<br />
<br />ACCOUNTING ONLY: AID# FAC #
<br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE
<br />d5o, 15'9 - S 9 - / _FA> 4-r- (,1&10 sR#oosvo
<br />C-57
<br />
<br />WC
<br />
<br />-WAIVER
<br />
<br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC
<br />
<br />END 29-01 11/5/07 (WEB) WELL PERMIT APP
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