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�� --- IL,E COPY <br /> D'"•.ga <br /> Can Joaquin County <br /> Environmental Health Department <br /> i 304 East Weber Avenue, 3rd Floor, Stockton,GA 95202 Jt MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd r,, " ���� UNIT IV <br /> A�/FoR Well Permit Application .F,Y, „ ' 'LIN : �S <br /> I � !/SER.VICr- 1' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application'lis hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliancewith San <br /> i Joaquin County Development Title,Chapter 9-1115.3 a the Standards of San Joaquin County Environmental.Health Department. <br /> y` Assessors <br /> WELL Location 1717 <br /> 1717 S. Center St �/ Cross Street Third St. pity Stockton/}� Zip 95206 Parcell## -PROPc^'� � <br /> OwnerERn C,J'"yr77 .Jgf /dress 725 Al' � City Stockton Zir�j Phone#. 3 '4 3 9 - <br /> -� - <br /> C-57 Contractor EnProb Env. Probing Address P.O. Boz 6093 - -City Oroville Zip 95966 Lic#777007Phone#(530)589-2019 <br /> Consultant/Sub Cntr ETIC Engineering, Inc. Address 2285 Morello Ave. .CityPleasant Hill Lie# 624022 Phone# (925)802-4710 s <br /> GIS Coordinates:X -121.285200 ,y 37.934700 t/ Township 1 North Range 6 East Section 14 <br /> WORK TO BE PERFORMED: <br /> ( ,$NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION (choose type below) <br /> -gSOIL BORING# (78 - a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a"Other GROUT SPECIFICATIONS <br /> l <br /> COMMENTS: - -- - <br /> i. TYPE OF WELL INSTALLATION TYPE . CONSTRUCTION SPECIFICATIONS- - <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE3" . a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: - <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS - TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:, GAUGERS $HOSE <br /> a AIR SPARGE/OZONE gPUSH POINT(GP or CPT)GROUT SEAL PUMPED:.gYes; a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> XSOIL BORING a HAND AUGER GROUT SPECIFICATIONS Neat cement <br /> a OTHER: a OTHER APPROX.BORING DEPTH 55 R.bgs a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> l � CONDUCTOR CASING PROPOSED none . (if YES,list specifications in comment section)V- <br /> COMMENTS: ...a <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, Rules and Regulations, and all applicable California State Laws. <br /> Signed I I Title/CompanySVv!q, I <br /> Print Name - Oen*S� Date- AD-A-IOA - <br /> ' .DEPART fNT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS. /717 S• (�« Gd� b !I <br /> I WORK PLAN DATED:• -0 <br /> ApplicationlAccepted By _ Date Issued l/-Y�o Area D,- <br /> { Grout Inspection By Date Final Inspection By - Date <br /> r. Destruction Inspection By - Date - <br /> �: COMMENTS I CONDITIONS: - <br /> 1 ACCOUNITING ONLY: AID# - FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> - <br /> C-57_I WC -WAIVER-- C-57 Letter of Authorization to sign permit_Encroachment doc_ /7/�J <br /> 77p <br /> EHD 29-021007 <br /> 6/22/04 I .. <br />