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San Joaquin County <br /> 1 Health DepartmentSITE <br /> z. Envikonmenta <br /> n' < 600 E. Main Street, <br /> Stockton, CA 95202-3029 {MITIGATION I <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV F <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 andfor install the work deschbed. This application is made in compliance with San <br /> San Joaquin Count Environmental Health Department. <br /> Standards,of Sa q Y <br /> Joaquin County Development Title,Chapter 9-11'f 5.3 and the S Assessors <br /> WELL Location <br /> 1930, West Fremont Street Cross Street City Stockton yip n 1203 Parcel#_ 13'' <br /> PROPER TY <br /> Marge Comer Address 4639 Ridgewood Court City Stockton Zip 95212 phone# 9B5-1458 <br /> Owner <br /> Shaw Road Cit. Stockton Zip 95215 Lic# 680227Phone#467-1006 <br /> B37 <br /> C-57 Contractor AGE Address <br /> Consultant 1 Sub Cntr.AGE Address City Lic# Phone# <br /> i <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORT(TO BE PERFORMED: <br /> [y,NEW WELL! BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, OTHER') p DESTRUCTION (choose type below) <br /> 0{SOIL BORING# B-1 D <br /> OVER-BORE. DIAMETER <br /> - <br /> a WELL# 0 PRESSURE GROUT <br /> +' <br /> 0Other GROUT SPECIFICATIONS <br /> j COMMENTS: <br /> a TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> O'MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2 I' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:NA__ <br /> �. 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS- NA TYPE OF CASING: a STEEL a PVC 0 OTHER: <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 20TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE Qi PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> l [YSO1L BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Cement <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 20' j] BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> s CONDUCTOR CASING PROPOSED NA (if YES,list specifications in comment-section) <br /> COMMENTS: <br /> r <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTION& <br /> I hereby certify that I Oave prepared this application-and thatthe work will be done in accordance with San Joaquin <br /> County Ordinances;:-,Rules and Regulatior}s;-and all applicable California State Laws. <br /> Signed x _,' � f �U r.' TitlelCompany Vice President <br /> L <br /> Print Name' Robert Marty ;' Date 0711-07 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: E q ..3-6 ►-v <br /> WORK PLAN DATED: t% ra <br /> a. Application Accepted By 1 YLL— Date Issued Area. t 1 <br /> Grout inspection BFinal Inspection By Dated-r7A/11r=f <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> I <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> Sq.� ��� 3 t `� -k�, �o sR# a oS�32 1&A5-� <br /> C-57 I/ WC--WAIVER C-57 Letter of Authorization to sign permit Encroachment doC <br /> EHD 29-02-001web <br /> I 5/22104 ` <br />