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( .4.S v!Luattl OD RECEOVElt ORIGINAL
<br />,ATE
<br />San Joaquin County
<br />Environmental Health Department
<br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd
<br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 NOV - 9 24fiTIGATION
<br />Well Permit Application
<br /> ENVIRONMENT HEAL
<br />PERMIT/SERVICES
<br />OA/ Mfif
<br />UNIT IV
<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 />WELL Location 23/S-- Ftgovi14 5:7 Cross Street 6, awe I4-' City flibe"#'4.4) Zip LS"--Y Parcel# 3 "7-"wa VI
<br />Assessors
<br />PROPERTY , Address -CST ,#1',44A/Cityffeedeiaiv Zip q547// Phone# Z0 4' e7,57 6CM; Owner HaC-->1) 104C mi
<br />0, sizecAs
<br />C-57 Contractor ,SecrAtkii, 6)044-- Address?? (44/,4 ik 4144 46/2 • City eeito41 Zip ,e-3 LJ4-)Lic# Phone# 2-14711 4/6,r- -,k77Z
<br />/ Sub Cntr 6-17/114, Address 1'0 2 .5141-y4e4(444C)rtyAwFccWLiC#77o7 Phone# tks, 7‘•, —//17 okiy n' e//
<br />GIS Coordinates: X , Y Township Range Section
<br />W RK TO BE PERFORMED:
<br />EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below)
<br />SOIL BORING # D OVER-BORE. DIAMETER
<br />WELL # /1141/ lp,k5 , 6,0 '62 a PRESSURE GROUT
<br />U *Other GROUT SPECIFICATIONS
<br />a _ ,
<br />COMMENTS: 4// AN/ reyve._ WPu_ A t';< s3- / i , /6, ,,-6.(9 s x yo ,
<br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br />;a/MONITORING
<br />U VAPOR
<br />EXTRACTION
<br /> ?f4HOLLOW STEM
<br />fl MUD ROTARY
<br /> CASING THICKNESS 5C:// O TYPE OF CASING: a STEEL %PVC a OTHER: a AIR HAMMER/DRIVEN DIA. OF BOREHOLE
<br /> a MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA:
<br />DEPTH OF GROUT SEAL 44/ 6-5 TREMIE TYPE TO BE USED: 1AUGERS 0 HOSE
<br />U AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: %Yes 0 No (NOTE: MAXIMUM FREE- ALL DEPTH IS 30')
<br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ..--4---",- -61 hi 7 CI A 1.7- ...4' 1.6 5 .4c/Z -6-,--/-76-7(-7-
<br />D OTHER: a OTHER APPROX. BORING DEPTH SS- ir-c) 5'67 i *30LTED TRAFFIC BOX or a STOVE PIPE
<br />.. CONDUCTOR CASING PROPOSED_ (if YES, list specifications in comment section)
<br />COMMENTS: b c- leiv-i or 6‘</earr SA- /S ,i-4.5.----'3 6: , ir „Lo ,_-_, yi '
<br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS.
<br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS.
<br />Application Accepted By c2A/ Date Issued
<br />Date Final Inspection By date (0 40 —a C. Grout Inspection By
<br />Destruction Inspection By
<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, Rule and Regulations, and all applicable California State Laws.
<br />Title/Company 0,/ /4
<br />#1 X'•-A- chi
<br />Signed x
<br />Print Name Date
<br />DEPARTMENT USE ONLY
<br />SITE MAP IN UNIT IV FILE, ADDRESS: c25/5 iV.54-46 Ge,"7
<br />WORK PLAN DATED: /6 2-? -05
<br />Area 61-42,,W
<br />Date
<br />COMMENTS / CONDITIONS:
<br />ACCOUNTING ONLY: AID# FAC#
<br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P EQUEST # INVOICE
<br />1(6.5 S CI / 0 k;. CfrA 11,-7 Syt 0 Otfle Ili._
<br />WAIVER C-57 Letter of Authorization to sign permit E
<br />
<br />EHD 29-02-001
<br />6/22/04
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