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oU1man Joaquin County <br /> Environmental Health DepartmentE n <br /> " { 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 �r! <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ey -� <br /> Well Permit Application FNRON, <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUaR"j <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This a{ <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Heath <br /> Assessors <br /> WELLLocation 1081 W. Mendocino Cross Street Pershing City Stockton_ Zip 95202 Parcel# 113-140-02 <br /> PROPER <br /> Owner . of the Pacific Address City. Zip Phone# <br /> 3601 Pacific Ave Stockton 95202 209-946-2541 <br /> C•57 Contractor � �f Address x07 11e00-- City p c# W1aone#QST- <br /> Consultant/SubCntr ESA Address 225 Bush St#1700City SE Lic# Phone# 415-896-5900 <br /> GIS Coordinates:X 2178929.0 Y 6327311.3 Township % 2N Range 6E Section 6 <br /> WORK TO BE PERFORMED: <br /> D NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") STRUCTION (choose type below} <br /> D SOIL BORING# OVER-BORE. DIAMETER 6.5 <br /> D WELL# . 0 PRESSURE GROUT <br /> D`Other GROUT SPECIFICATIONS <br /> COMMENTS: Wells are pre–packed in 2.5" borings – overdrill using 6.5" HSA <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL 0 PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: f1 OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or D 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 /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina R es and ulations,and all applicable California State Laws. <br /> Signed x /+/ * T, pa 1/17ano�cw �� /�lj <br /> Print Name (�//� Date <br /> DEPARTMENT USE OKLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /O 81 <br /> WORK PLAN DATED: <br /> Application Accepted By `�'1 Date Issued Area_ y <br /> Grout Inspection By Date Final Inspection By T-777 Date <br /> Destruction Inspection By �i�jry'S cG, 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 /> SR# q;- 1 -? .3 <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 />