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San Joaquin County
<br />Environmental Health Department
<br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202
<br />LAEcp7,/ipirnsiTE ,
<br />- - Att TIGATION
<br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/eht E 5 2005 UNIT IV
<br />Well Permit Application
<br />ENVIRONMENT HEALTH
<br />Div ORIGINAL
<br />ERMI NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P T/SERVICES
<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 />Assessors
<br />WELL Location /'/70 -r e Cross Street Zoe, //L', City Z;&."-.77 Zip 7-5-J-Lie Parcel# -?;:e
<br />PROPERTY
<br />Owner le ig( ..)roPseS Address /4 8ox °15 City /14 eo.;riIIZZIp 11472Phone#
<br />C-57 Contractor L..C:licign4 ee-y Address 1e.N ale C- -e/ City c-.4.:‘,:f0:ver Zip 7(2 Lic# 717510 Phone# (4w,) erjer
<br />Consultant / Sub Cntr5reet ..7:4.4&://e4/41-kldress leY7 iefre 1211419City 4.et":44 Lic# Pe' Phone# 4trier•i/- °Vet)
<br />GIS Coordinates: X , Y , Township Range Section
<br />WORK TO BE PERFORMED:
<br />)(f NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below)
<br />a SOIL BORING # a 0 V E R - B 0 R E . DIAMETER
<br />XWELL # 2 a PRESSURE GROUT
<br />O *Other , GROUT SPECIFICATIONS
<br />COMMENTS: 66;4/ weisf e-e,:_cliwc ?1,- ee .-sc--ci--, /5 i ' /,,./4c, Je&Y.-1 ..•7_7‘y- te,5eV .4.4, (4, ?E: ••._.c ?z:f
<br />C e. • . ce'ci.e "-',-
<br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,-,
<br />XivlONITORING XHOLLOW STEM DIA. OF BOREHOLE g " 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <7
<br />O EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS.5c4 90/It-TYPE OF CASING: a STEEL XPVC a OTHER:
<br />0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL /-.5- -- TREMIE TYPE TO BE USED: ICAUGERS a HOSE
<br />0 AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: )(Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30')
<br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS .d/eat Cc
<br />['OTHER:,w5,141 ;Hcf; 1 % APPROX. BORING DEPTH 75" ABOLTED TRAFFIC BOX or a STOVE PIPE
<br />i 1 5. . DUCTOR CASING PROPOSED c (if YES, list specifications in comment section)
<br />MENTS: ? %/P e/ 1;i;i 0-,040- ..$-X'e/,--,,,,,re,,,- 4.- e--,...r.i>lii ,,-.,_r/44..."/ /a, 51.,f -
<br />.,4-,-. 0.7I 4;4 _s-7e -<--e ,/,..). , /" //c.i, .$21,k,., 4-....), ci-s a..// 4
<br />NOTE: OFFSITE BORINGS REQU
<br />,
<br />IRE 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 Regulations, and all applicable California State Laws.
<br />‘.e.0 ‘6,-J-7` e- (D/f) Title/Company _r6
<br />Date
<br />DEPARTMENT USE ONLY
<br />SITE MAP IN UNIT IV FILE, ADD ESS: /600 4,446t4IF
<br />WORK PLAN DATED:
<br />Application Accepted By Date Issued 0.5 Area aig
<br />Final Inspection By
<br />4i27
<br />Date
<br />411.
<br />ACCOUNTING ONLY: AID# FAC#
<br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P UEST #
<br />----,
<br />INVOICE
<br />3 5(3 t 1\40 T. (0,c(ov./ gs4z 1 .215 r# oolf‘tteiv
<br />)
<br />C-57 17 WC -WAIVER C-57 Letter of Authorization to sign permit
<br />
<br />Signed x
<br />Print Name
<br />,egiv,:defrcf;
<br />Grout Inspection Inspection By Date
<br />Destruction Inspection By
<br />COMMENTS I CONDITIONS:
<br />Date
<br />EHD 29-02-001
<br />6/22/04
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