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<br />San Joaquin County
<br />Environmental Health Department
<br />' 0 East Main Street, Stockton, CA 95202-3029
<br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd
<br />V 2 '72007 Well Permit Application
<br />HEIVIREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />Application is hertitRigilVt5ZOligtitin County for a permit to construct and/or install the work described. This application is made in compliance with San
<br />SITE
<br />MITIGATION
<br />UNIT IV
<br />ENVIRONMENT
<br />PROPE_RTY .
<br />Owner Zp.,. 1,3-• 2.-, k -1,--,scs a-c Address 201YS" -.5L4Je City 5 0-- zip 94.)E7o Phone# 71)7 -86Y - /0 /7
<br />C-57 Contractor F,-/-//"Ker--,`c.- D 1 1d 3/q5—Z City4-4/-c41%5' 757eLic# 879 9t S'Phone# q/4„ 7Y(7 0-
<br />(Consultant/ Sub Ontr A 5s Address ik 23 c5 Phone# /o/ — 733 -l36,
<br />GIS Coordinates: X
<br />
<br /> Township Range Section
<br />
<br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.
<br />On • C I Assessors WELL Location 35/c //:,,./ Cross Streetffre/1 un City _2 roe: ic ro, Zip Parcel# /4 2 o-3a) z
<br />WORK TO BE PERFORMED:
<br />ANEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*)
<br />Al,,SOIL BORING # - I , -54 -2c-.)
<br />vytIr AWELL#V -1/ V -% t,r-1 it I -.5:.11-6/ (4-'2/ - I
<br />• a *Other
<br />COMMENTS: V. ll.s - IA., „cf- 4, (tel c„.,(7.;
<br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br />it 0 MONITORING a HOLLOW STEM DIA. OF BOREHOLE Z/ "(MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _P__,_25-
<br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS itIA TYPE OF CASING: 0 STEEL a PVC a OTHER: 're On, r c.—.4c
<br />
<br />//(VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 5 5-faVS (4 TREMIE TYPE TO BE USED: a AUGERS a HOSE
<br />O AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes /4 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30')
<br />a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /4) zi,-,,_/c_q ge.4--o,,, /--e - (-„, v-,- ,i. e ac,
<br />El _Z
<br />
<br />OTHER: ,OTHER A i (-kr.; Ic, APPROX. BORING DEPTH 64-, To- XBOLTED TRAFFIC (OX or 0 STOVE IPE 7
<br />CONDUCTOR CASING PROPOSED_ Ai 0 (if YES, list specifications in comment section) 56 ,i
<br />COMMENTS: V‘WL tve (13 Le‘ i l e , -skii,./ 1.,5, "-41 0. Zi. (I 7---1(0,,. 7-4,,,,',„ 1....1ki. 3 `` of 5-cf:-,-- 's 5/ —;e' 6„_s ,-,5 1. ,/ A.i'L.3" /" Q't V 'I. r..1 i'e' 4.-- IT X, /10-) 4J Ay.),--4,1 &-Y.-.1-1--/-‘esc"cc NOTE: OFFSITE BORINGS REQUIRE 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 />Signed x
<br />Print Name
<br />
<br /> Title/Company 611,"...e5 /1.4
<br /> Date 045 --e-7
<br />
<br />SITE MAP IN UNIT IV FILE, ADDRESS:
<br />WORK PLAN DATED:
<br />DEPARTMENT USE ONLY
<br />7c-/
<br />
<br />O DESTRUCTION (choose type below)
<br />13 OVER-BORE. DIAMETER
<br />13 PRESSURE GROUT
<br />GROUT SPECIFICATIONS
<br />Grout Inspection By
<br /> Date Issued ///)-57/0? Area 7q7
<br />Date bli (c/ b"/ Final Inspection By
<br />Date
<br />CA-1 L14/ 0.4 C C- (.3 • dr"
<br />Application Accepted By
<br />Destruction Inspection By
<br />COMMENTS! CONDITIONS- / r, ,
<br />Date
<br />ACCOUNTING ONLY: AID# FAC#
<br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE PERMI-T-i-SFAVICg. R
<br />3S-01 ci _ n - c7c,‘ t-Pr- h 2i1 SR# 0 0 0.- 7 & e
<br />-WAIVER C-57 Letter of Authorization to sign permit Encroachment oc C-57 WC
<br />EHD 29-02-001 WEB
<br />9/1 1/2007
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