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0 • <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> "{ k� 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209)468-3449 Fax:(209)468-3433 Web:www.siaov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> Assessor's <br /> Well Location 3190 Auto Center CirCross Street Hammer Lane _ City Stockton Zip 952 fe Parcel# 218-020-24 <br /> Property -219 <br /> Owner Mike Santin Address 46775 Mountain Lane City Indian wells Zip Phone# 760-219-0111 <br /> 105 Loma Vista Dr Orville Lic#7770077Phone 530-589-2019 <br /> C-57 Contractor Enprobe Address City <br /> Consultant/SubCntr Partner E&S Address2101 Rosecrans Ave,#427(bity El Segundo Lic# Phone 415-962-4755 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> [3 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) E] DESTRUCTION(CHOOSE TYPE BELOW) <br /> [�}SOIL BORING# Six ❑ OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑'OTHER _ GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLEI.75 in❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE [PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS C ly <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 15 feet [I BOLTED TRAFFIC BOX OR []STOVEPIPE <br /> CONDUCTOR CASING PROPOSED (i(YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> ORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have preparajrnl <br /> cation and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a Iicables. <br /> Signed Title/Company Partner Engineering and Science <br /> Print Name Kerran PenderDate March 10, 2009 <br /> /DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: t� C( v 6A"_� <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY ��-e7 DATE ISSUED v _AREA9��J��' q <br /> GROUT INSPECTION BY FINAL INSPECTION BY ' DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> �Ip $ SR# X81_$ <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PEROT ENCROACHMENT DOC <br /> EHD 29-01 11/5107(WEB) WELL PERMIT APP <br />