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WELL PERMIT APPLICATION FOJECRAP- <br /> SAN JOAQUIN COUNTY IGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHDjlll�- <br /> 304 E. Weber, Third Floor, Stockton, CA., 952IIRUNMEN U AI IV <br /> (209) 468-3449 PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FRQM DATE ISSU D <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicatfon is made in compliance with San <br /> Joaquin County Development Title,Chapter 81115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 3333 West Hammer Lane Cross Sireel Mariners Dr City Stockton _Zip- 95219 Parcel# 071-180-14 <br /> PROPERTY Owner Gil Wvmond ,Address PO Box 380 City_Riverbe k Zip 951§7 Phone# <br /> C-57 Contractor Resonant Sonic Address 220 N.East Street City Woodland Zip Lfc# 802334 Phone#_(530 668-2424 <br /> Consultant Sub Cntr ATC Associates—Address 6602 Owens Drive, Suite 100_City Pleasanton CA Lid# PhoneaT"ZS)i{40-S36Q <br /> GIS Coordinates:X 'y Township Range Section <br /> WORK TO BE PERFORMED <br /> p NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HANDAUGER,OTHER') [x]DESTRUCTION (choose type below) <br /> 0 SOIL BORING# [xj OVE"ORE.DIAMETER 8 <br /> o WELL# 0 PRESSURE GROUT <br /> 0'Other GROUT SPEMATIONS: Tremie <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPiE CONSTRUCTION SPESPECIFICATION VW .7 <br /> [xl MONITORING 0 HOLLOW STEM DIA.OF BOREHOL 0 MULTIPLE CASINGS 0 MULTF-LEVEL WELL CASING DIA: 2- <br /> 1]EXTRACTION p AIR HAMMER/DRIVEN CASING'THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 40APOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREINIE TYPE TO BE USED: 1]AUGERS 0 HOSE <br /> IR SPARGEI OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> p OTHER: Ix]OTHER destruction APPROX.BORING DEPTH [I BOLTED TRAFFIC BOX or d STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in oomment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> i <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordln ces,Ru Regulations,and all applicable Callfoinia State Laws. <br /> Signed ( Title/Company_S'' <br /> Print Nap4/ Date //e/oG <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 5- We-s+ Pamms= Lann <br /> WORK PLAN DATED: Ju 1 t4 2 <br /> Appllcation Accepted By V i Gftrr:a L. MaCarlazy Date lssued___, U�V �SI2olJG _ Area 1¢Sq <br /> Grout Inspection By date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> �e <br /> a <br /> G ONLY: AID# FAC# <br /> FEE INFO AMOUNT REMITTED CHECK alk RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 10'...00 60, Do SR# oo474- oo <br /> C-57— WC-WAIVER_ C-57 Letter of Authorization to sign permit,Encroachment doc_ 9/30/02 <br />