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SAN JOAQUIN COUNTY
<br />ENVIRONMENTAL HEALTH DEPARTMENT
<br />600 East Main Street, Stockton, CA 95202-3029 igTEalATION
<br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov,orq/ehdL- UNIT Iv
<br />WELL PERMIT APPLICATION mA`f 2 2 MB
<br />
<br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSM:' fiRONMENT HEPLTH
<br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app rl
<br />ca s
<br />me ir
<br />a compliance with San
<br />Health Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental He Department.
<br />
<br />c.‘,‘ Assessor's--
<br />Well Location ,c-1 1 W ‘-k, ,. \- Cross Street CAO.,-ek- ,..-i-1..... City
<br />Zih
<br />p Parcel # \ ‘-'1 - 1 ii - 3
<br />s.voc...ccxN i ./SaPR\lICES
<br />Property cl. 90 cyvt c cx....„:3
<br />Owner -c, .--\ c.c. c Vo Address City i\Ne4 0•44AV Zip c\ S -1-31-,Phone # 2.A ci • °A1/4"'‘ l' u(evir
<br />C-57 Contractor(---xi'Sc..•-v.,3‘.. Oc'•\\:\ ev; '5Nt\4, '-' Address -S1/4.,2 4 2- C:YrY‘0-4. C.:-.4%.\42.., City 23*-X- 's. Zip 95 ls-kLLic # 1 \ 15' 0 Phone t
<br />i
<br />Phone `1%\:. • '-\ Sf S. • tc);:i lf 1/4:I
<br />el sl) (-4 \Ad.. -e-, s-„zeca. ix-•
<br />4._.i.4. 14-
<br />Consultant/Sub Cntr f\ ---C---iN. \ Address City T-:3l cv-v•-, Lic #
<br />GIS Coordinates: X
<br />
<br /> Township Range Section
<br />
<br />WORK TO BE PERFORMED:
<br />-r1 NEW WELLJBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) D DESTRUCTION (CHOOSE TYPE BELOW) gt SOIL BORING# c,rxx S
<br />*OTHER
<br />WELL # - Z., vN \%3 IN'Nk, -S
<br />0 OVER-BORE DIAMETER
<br />0 PRESSURE GROUT
<br />COMMENTS: 1—C3C.....cr•V\ <,-x-N c...NNA c\.4z,._9•\,, .\., SL -1-- k^s'',\\\* \e,0-10, CNN a t--...v,0,, Lavq._,,,ct, ,ki 4yzry,
<br />. \Of\ \,-- -"1/43• . Cf,-,Y,l' YN\\,-: --S .
<br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br />fit MONITORING "lit) HOLLOW STEM DIA. OF BOREHOLE S' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:
<br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER
<br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ''--- S S.' ' TREMIE TYPE TO BE USED 0 AUGERS WHOSE
<br />cts,_,
<br />I: AIR SPARGE/OZONE El PUSH POINT (GP OR CPT) GROUT SEAL PUMPED:' Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30')
<br />c.
<br />
<br />9:S0IL BORING 0 HAND AUGER GROUT SPECIFICATIONS 514 .%4Lxv6;.1 44:3, - c--c-‘:>•Ask 'M.\ )0r1/4-)v“..,"' us)
<br />0 OTHER: El OTHER: APPROX. BORING DEPTH
<br />
<br />ug BOLTED TRAFFIC BOX OR 0 STOVE PIPE
<br /> (if YES, list speclications in comment section)
<br />C)c)
<br />CONDUCTOR CASING PROPOSED
<br />COMMENTS:S(5-2_ 13.) cennAf (1,4c.S 1rr coinIc. cIyt:km
<br />
<br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS
<br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 3-
<br />I herebyhereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and
<br />Regulations, and all applicable California Laws.
<br />Signed f X%\t\vy.. Title/Company ¶)L CL CA b,
<br />Date S1 LA 0 V
<br />GROUT INSPECTION BY k./AAAA..C4/n fo tr+I(9 ci. FINAL INSPECTION BY (A>AA4/t0.-\ DATE 4HOSS---
<br />DESTRUCTION INSPECTION BY DATE
<br />COMMENTS/CONDITIONS:
<br />ACCOUNTING ONLY: AID # FAC # gRiv5 103 1-'3
<br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE _ _ . INVOICE
<br />../a- 3/45 SR# 5 Li 333
<br />C-57 WC -WAIVER
<br />
<br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT 1_,/ ENCROACHMENT DOC
<br />
<br />GROUT SPECIFICATIONS
<br />Print Name
<br />DEPARTMENT USE ONLY
<br />SITE MAP IN UNIT IV FILE, ADDRESS: 3 c13- Sr 5 • 1.4w-11,1
<br />WORK PLAN DATED: I Z. I I .8 1 3—(avideiAdlnIv.i) )114 6.7 - (cAir .)
<br />APPLICATION ACCEPTED BY 1iN1"..,....cc.N. DATE ISSUED SIZ-1/C.IC AREA
<br />END 29-01 11/5/07 WELL PERMIT APP
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