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t ILL GOPY <br /> _ian Joaquin County <br /> t <br /> Environmental Health Deparm <br /> A SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, cA 95202 <br /> MITIGATION <br /> (209)468-3449 Fax. (209) 468-3433 Web: vvww-sjgov.or'g/eIid 2007 <br /> UNIT IV <br /> " <br /> Well Permit Application V 'EAS�TH <br /> L <br /> NON-REFUNDABLE PERMIT EXPIRES 11 YEAR FROM DATE ISSUED L <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 /> Assessors <br /> WELL Location 244 W. Hardin q Way —Cross Street Monroe Ave. City.'Stockton -Zip 95204 Parcel# 137-080-14 <br /> PROPERTY <br /> Owner SINGH,INDERJIT Address 6809 BROCKFALLS Cir.City <br /> LjTCCKToN Zip 95219 Phone#_La23_LL48-8()oj <br /> C-57 Contractor Grego Dri]jan�L_Address 950 Howe Ave, Cjty_Z22��ZiP_2.4553LiC# 6_56407 Phone# (9251313-5800 <br /> Consultant i Sub Cntr. Adyanr.&.6 (-&nT?nyjj-_�.Address AV7 Shaw M City Stockton Lic#-LZL12_2_Phone#__L2L91462-1LQ_6__ <br /> GIS Coordinates:X 'Y Township Il Ran.ge_Section <br /> WORK To BE PERFORMED: <br /> gNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*') 0 DESTRUCTION (choose type below) <br /> it SOIL BORING#CPT-1,CPT-2,B-6 DOVER-BORE. DIAMETER <br /> GVVELL# MW-4 MW-5 U PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: E :1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> II ,MONITORING "HOLLOW STEM DIA.OFBOREHOL?"'_"''Wi6LT)PLECASIN'GS 0MULTI-LEVEL WELL CASING DIA:-?" <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS SCHD 4 0 TYPE OF CA�ING: a STEEL ff PVC. U OTHER: <br /> CPT/B=SFC-T0,M I 54_ff� <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL :AVE TYPE TO BE USED! (JAUGERS 0 HOSE <br /> a AIR SPARGE!OZONE It PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 11 Yes 0 No' (NOTE: MAXIMUM FREE-FA/i DEPTH IS 30') <br /> ff SOIL BORING a HAND AUGER GROUT SPECIFICATIONS ; Type Il Portland <br /> a OTHER: <br /> _a OTHER— APPROX.BORING DEPTH BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED- (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4U 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. gul4tins and all applicable California State Laws. <br /> Signed x <br /> —Title/Company. qt-Aff FririrLMmpnt-ai scient-igr <br /> Print Name Ajiqnn (,,,l Date <br /> _Lj_&_Lrj:j <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: W19 <br /> WORK PLAN DATED:- I Jdnlja r!d 3, a Ld— 0 c4 i 1,-P_/, :30 .7-006 <br /> OF <br /> Application Accepted By <br /> Date Issued 9i 0 Area <br /> i0for'.a W16424A!!!, Date_ t, <br /> —Final Inspection' <br /> Grout Inspection By By WIt,,4S .+�Dt. -0 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: Ad%jay1,-,en2_Pf -f r_f'r-I Ce T- 2 JB_G 4nd;nuf:';114, LdL4a <br /> 6— <br /> ACCOUNTING ONLY: AID# FAC# 0 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# SECIDBY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> ,374- 00 2.5-1,qq SR# <br /> -ZES .1-0 005-09& 13 <br /> C-57— WC=WAIVEP, C-57 Letter of Authorization to Sign permit_ Encroachment doc <br /> ERD 29-02-001 <br /> 6/22/04 <br />