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° San Joaquin County <br /> c <br /> _ z Env► onmental Health Departmento c' r <br /> � <br /> ° 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 � ON <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd JUN 3 0 WT IV <br /> F° Well Permit Application <br /> EIVVfHONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMMSERVICES <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 508 Charter Way cross sbAssessors <br /> Street citystockton Zip Parcel# <br /> PROPERTY <br /> OwnerSurinder Saini Addresg506 W. Longview City StocktonZip95207Phone# <br /> C-57Contractor Precision Address1 0,91 F.cgPX Ajrp R chmondZip 94841 6363Agnalm ( 510 ) 237-457. <br /> Consultant/Sub Cntr SECOR Address3475 WestShawCityFraGnnLic# Phone#( 559 ) 271 -2650 <br /> GIs Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ¢NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> a SOILBORING#9 direct push DOVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> r•Other 9 CPT GROUT SPECIFICATIONS <br /> COMMENTS:Total depth at load- 90 ff- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 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 TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> t SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 5 0 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:—Nn_ Wn l l g W i l l he i n,;f-a l l ori <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 Title/Company Staff Geologist <br /> Print Name RaV Tugman DateEt/2Q/05 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <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 I SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />