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Environmental Health Department SITE
<br />304 Fast Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION 6 200 7
<br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgoy.org/ehd
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<br />UNIT IV
<br />Well Permit Application
<br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE -
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<br />Application Is hereby made to San Joaquin County for a permit to construct and/or install the wort described. This application is made in compliance with San
<br />WELL Location pi p .1 .,
<br /> I j . N — c''‘._'‘ s.-- tz
<br /> „..-, „ Assessors t e...' (...'-‘,
<br />i ..e? 0t5 Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.
<br />vy ,,,.yavN• k-I ?-'1.0-1 Cross Street 1--kl'' - 4e,' City 1 cc. tt.L.,'N. Zip '17 AO-, Parcel# - .
<br />PROPER7 , ,
<br />Owner '4:,,,):Y'1/4 k.ft; ,-...,1 (0,--j., -D Address .;.?---'' 1 AY,,,,11-(4:t./ 'r- City L ..:,,,z-%,,,,,-,: zip 'IL/ 5--31Phone# (1' 351- Li Li ? - i V
<br />C el), k tirc:V City 'iCPhone# 9 C-57 Contractor Address :5( i(
<br />
<br />Address 'L elicit Ai 'J Phone* 9;2-5-- 't-3-t( 3'tr Consult ant/Sub Cntr I
<br />, San Joaquin County IL LI \ I H
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<br />GIS Coordinates: X Y Township Range Section
<br />WORK TO BE PERFORMED:
<br />cIPNEW WELL! BORING
<br />_.--B=SOIL BORING #
<br />1:1 WELL ft
<br />I] 'Other
<br />COMMENTS:
<br />O DESTRUCTION (choose type below)
<br />
<br />OVER-BORE. DIAMETER
<br />U PRESSURE GROUT
<br />GROUT SPECIFICATIONS
<br />- tof k2k •••• e . i
<br />
<br />r •
<br />0(CPT, GE PROBE, HYDROPUNCH, HAND-AUGER, OTHER')
<br />-fl-MONITORING DIA. OF BOREHOLE re a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: ____
<br />a EXTRACTION CASING ;41gggia4- 2 TYPE OF CASING: (]STEEL Il\VC a OTHER:
<br />a VAPOR DEPTH OF GROUT SEAL J-: i TREMIE TYPE TO BE USED: A'AUGERS a HOSE
<br />_.,.I
<br />U AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUF, FREE-FALL DEPTH IS 30')
<br />[ISOIL BORING U HAND AUGER GROUT SPECIFICATIONS
<br />U OTHER APPROX. BORING DEPTH /.1 ,"%) BOLTED TRAFFIC BOX or U STOVE PIPE
<br />CONDUCTOR CASING PROPOSED i", (if YES, list specifications in comment section)
<br />1•YNO t -40 1-1 Yk..\ I.Je_LLs ,ao r -tc..( ) s-
<br />5 50 ,1 lo rt stiaA .5 I 4-6 5-01 T L-1 4-0 ,2-4 4- 6 / mr
<br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS
<br />TYPE OF WELL CONSTRUCTION SPECIFICATIONS INSTALLATION TYPE
<br />N'OLLOW STEM
<br />a AIR HAMMER/DRIVEN
<br />fl MUD ROTARY
<br />OTHER:
<br />COMMENTS:
<br />•
<br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS.
<br />A/7
<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 Regulations, and all applicable California State Laws.
<br />S 17•-',/ 1 . 7 I) i1 , • !
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<br />/ Title/Company .- ' '' - • / -7 Signed x
<br />
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<br />/ .. e ,...1.10,--- ..-- ' — '' 1 . / . , Print Name tA ,-; .4/1 V /7 vl Date -- — I L.-1 i ., '7 i \J./w.f./ e4,0, I ,... ,y LY , f
<br />DEPARTMENT USE ONLY
<br />SITE MAP IN UNIT IV FILE, ADDRESS: 3 -7 3 -7 (4) t I 56 n kid
<br />WORK PLAN PLAN DATED: 511516 -7
<br />Application Accepted By
<br />Date Issued -7/ Area 7 (1 2-
<br />Grout Inspection By Date "5-1-1.--tt ,71- Final Inspection By Date
<br />Destruction Inspection By Date
<br />COMMENTS / COMMONS.
<br />ACCOUNTING ONLY: AID* FAC#
<br />_
<br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE
<br />--C.1 0 I 13c) 4. Kg 1 IP 5-5-C SR# 50co d,7
<br />C-57 WC -WAIVER
<br />
<br />C-57 Letter of Authorization to sign permit Encroachment doc
<br />EilD 29-02-001
<br />6/22/04
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