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�naa°iN �q an Joaquin Couty FILE VO/ Y <br /> r <br /> j Environmental Health Departmen>tr�:���( ';i�' i <br /> N -, SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 L <br /> (209)468-3449 Fax: (209)468-3433.Web: WWW.Sjgov:org /` 2 c) "•"�IGATION <br /> 1 <lFORN`4 l Zoo1 UNIT IV <br /> Well Permit Application + c��ly/r,f <br /> NON-REFUNDABLE PERMIT EXPIRES_1 YEAR FROM DATE ISSUED�k,, y.7., <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 /> WELL Location 1717 S. Center St, Cross Street Third St. Assessors <br /> City Stockton Zip 95206 Parcel# 165-072-28 <br /> PROPERTY _ - - <br /> Owner Ismael Rivera Address. 1717S. Center City-Stockton Zip 95206 .Phone# p <br /> C=57 Contractor EnProb Env. Probing Address P.O. Box 6093 City Oroville .Zip 95966 Lic#777007 Phone#(530)589-2019 4 <br /> Consultant/Sub Cntr ETIC EngineeringInc Address 2285 Morello Ave. City Pleasant Hill Licit 624022 Phone#1(925)602-4710 <br /> GIS Coordinates:X -121.285200 + Y 37 934700 Townsm �1 North e/' <br /> P Range 6 East Section 14 <br /> WORK TO BE PERFORMED• - <br /> )(NEW WELL/BORI ) _g DESTRUCTION '(choose type below) <br /> _IAC (CPT,GEOPROBE HYDROPUNCH,HAND-AUGER OTHER' <br /> gSOIL BORING# CB and C7 0 OVER-BORE. DIAMETER <br /> 0 WELL# <br /> 0`Other 0 PRESSURE GROUT <br /> . - GROUT SPECIFICATIONS 1 <br /> COMMENTS: - -- <br /> F <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 3" <br /> g MULTIPLE CASINGS 0 MULTI-LEVEL ,.WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 10 PVC p,OTHER:- <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL EMIE TYPE TO BE USED GAUGERS: g HOSE " <br /> 0 AIR SPARGE/OZONE $PUSH POINT(GP or CPT)GROUT SEAL PUMPED: KYes ,0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> g SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Neat cement _ <br /> 0 OTHER:_G OTHER APPROX.BORING DEPTH 55 ft.bgs 0 BOLTED TRAFFIC BOX .or H STOVE PIPE <br /> CONDUCTOR CASING PROPOSED none (if YES,list specifications in comment section). I <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 work will be done in accordance with San Joaquin <br /> County Ordin ce Rules d Regulations,and all applicable California State Laws. <br /> Signed x_ .. - ,l \Title/Company. �Nee1WM *z--, yL `rnu p tin► <br /> Print Name - v \h0`e+.i.� {�IQAJJ� Date W <br /> DEPARTMENT USE ONLY <br /> �/ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ��(� ,S. C� ; LOP D <br /> WORK PLAN DATED: 3 <br /> Application Accepted ByDate Issued Area <br /> - Grout Inspection By Date Final Inspection By Date I _ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# + FAC# - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3sbr 84, 2531 �� zz 'SR# p <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc 4 <br /> EHD 29-02-001 <br /> 6/22/04 <br /> f <br />