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Application Accepted By
<br />Grout Inspection By
<br />Destruction Inspection By
<br />COMMENTS / CONDITIONS
<br />Ar.VN,
<br />ci-A V 09 2007 Well Permit Application
<br />FOY(
<br />San Joaquin County
<br />Environmental Health Department
<br />600 E. Main Street, Stockton, CA 95202-3029
<br />, 68-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd
<br />uHlui NAL
<br />SITE
<br />MITIGATION
<br />UNIT IV
<br />ENVIRONMENT HEAETF-r
<br />Application is hfitEIRMRINC qatilporaquin County for a permit to construct and/or install the work described. This application is made in compliance with San
<br />Joaquin County Developrne-rifTitre,tV1pter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.
<br />WELL Location / t7 .17 fa( (lc Cross Street RI VIVA City 54-0(... idt, 61 Zip (75-2-03---- Parcel# c)77'/ 6c/
<br />Assessors
<br />0"wCinePrE"Yrk flt, 0; i
<br />ex 5 is-.
<br />_ _ . , _ _ Address I 3/ / -Tly-g.4 41 C't ck.tlet Fc V'bijZ•?ps2d670 Phone* -5r • - J Y -) 22-46 -4 3 P .51541(
<br />WORK TO BE PERFORMED:
<br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER5fr KDESTRUCTION (choose type below)
<br />0 SOIL BORING # >LOVER-BORE. DIAMETER t...,e...Lts /0• I c" 1.4-e4
<br />1:1 WELL # 0 PRESSURE GROUT 1
<br />e•cli 0 *Other GROUT SPECIFICATIONS .P)12-4-0 .14c (;v-0.4--
<br />COMMENTS: -It: Pe'54 c ,d-cii !, i i ie,, • ga , - — i ffe5s4ve. ii,),P P h...,,r1,
<br />/,',et • —A
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<br />COMMENTS:
<br />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 Ru es and gulations, and all applicable California State Laws.
<br />Signed x (-Na Title/Company
<br />Print NacnEr-%7t C-14,411' g4 e)",e, Cahl•-% '--- Date / 1 - 6 1
<br />DEPARTI7NT USE ONLY
<br />SITE MAP IN UNIT IV FILE, ADDRESS: 7‘7(1-7-
<br />WORK PLAN DATED: 4.tAJ -
<br />EFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />C-57 Contractor le4)-p.evDii i I .1. Address/O/ t E. k4,-k it.; 4vt City /kkeo..., Zip94%-i0c-Lic* e1,i5y,..rphone#7,4 9176;c5 -v
<br />a _4 1 14)0 .1 , Consultant/Sub Cntr &-o1214'd-ci.. (in".541 kir Address5/ I 2 bc..15ek r71, City rilt-v P L.. " - Lialtgt- _5-5-LC, Phone* 7/51616 Si-2-7--
<br />GIS Coordinates: X .9)V0110I.37W, Y /02./°/9 /;2.7,q114 , Township Range Section el, 5---, ,i4 ..., - 11-
<br />fro,' •-11/v0 -3
<br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br />a MONITORING -A.HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DIA:
<br />)KEXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC a OTHER:
<br />a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE
<br />O AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30')
<br />U SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS
<br />J OTHER: 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or a STOVE PIPE
<br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section)
<br /> Date Issued
<br />Date inal Inspection By
<br />Date 7.3-76-A) 7
<br />ACCOUNTING ONLY: AID* FAC#'7'7
<br />(4------gMfT-i-SPE)
<br />e-s
<br />'
<br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PErf318)-15CJEQUEST # OI CE
<br />3502_,, ‘‘Vp 4.o. .9121, 2-- SR# 05-2,47?
<br />r ,
<br />C-57_ V WC V -WAIVER
<br />
<br />C-57 Letter of Authorization to sign permit 4. Encroachment doc*
<br />EFID 29-02-00 lweb
<br />6/22/04
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