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o,qut>w an Joaquin County <br /> _•� -:% _ •�. Environmental Health Department o SITE <br /> FN < 304 East Weber Avenue, 3rd Floor, Stockton, CA 9522 �� � IGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> •� —� UNIT IV <br /> AUG 3 1 200_4 <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSIROfWIII�ECNppT��H� EALTH <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. f Vi8E f{WE6e in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Rose Marie Stockton 95207 1ssessorl132-280-13 <br /> WELL Location 4532 Pacific Avenue/Fronta%eross Street City Zip Parcel# <br /> PROPERTY 4532 Pacific Ave. Stockton 95207 <br /> Owner Oscar Sanchez Address CitZip Phone# <br /> All well Abandonment hamon Springs <br /> C-57Conlractor Address 6626 Merchandise way City Zip 95619 Lic#484359Phone# 530 644 1609 <br /> I <br /> Consuttant/Sub Cntr Advanced GecEnvironmentalRddress 837 Shaw Rd City Stockton Lic#_E3D22j ^Phone# (2091467-1006 <br /> GIs Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED- <br />', Q NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 8 DESTRUCTION (choose type below) <br /> Q SOIL BORING# J]OVER-BORE. DIAMETER B inch <br /> Q WELL# hA w 1� 19 PRESSURE GROUT <br /> Q"Other T GROUT SPECIFICATIONS Portland y <br /> COMMENTS: +vI c urL <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ff MONITORING j]HOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: 2-inch <br /> EXTRACTION AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: STEEL PVC OTHER: <br /> Q Q Q Q Q <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE!OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') C` <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER: Q OTHER APPROX.BORING-DEPTH - Q BOLTEI?TRAFFIC BOX-br Q 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances Rule and Regulations, and all applicable California <br /> /State <br /> �Laws <br /> Signed x U/[Y�l0.L�Ckf/`4� 'l Title/Company (7+�1' j�� L7� <br /> Print Name YVlikv, Date ��25 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS' ] C <br /> WORK PLAN DATED: S o a r <br /> Application Accepted By Date Issued Pt 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 1 SERVICE REQUEST# INVOICE <br /> 33`0 q;_a, uoq on� aaL1�C (i/ j SR# <br /> C-57 r�WC WAIVER_ C-57 Letter of Authorization to sign per mitfGEncroach ment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />