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yo CL �o n Joaquin CountyT. t <br /> Environmental Health Department REDE((--���VgRTE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> AUG 3 Y 2009L)NIT IV <br /> Qtoft� Well Permit Application ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVI� Q�+ <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application Is made incompliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. R <br /> 4511 pacific Avenue Rose Marie Stockton 95207 Assessors110-230-11 <br /> WELL Location Cross Street City Zip Parcel# <br /> PROPERTY Stockton951-1207 <br /> owner Art Wyatt Address 6265 Crooked Stick Ci6ty. Zip 95219 Phone# <br /> Diamond Springs <br /> C-57 Contractor All Wel/ Abandonmen ddress6626 Merchandise Way City Zip 9561q-ic# 484359Phone# 530 644 1609 <br /> Consultant I Sub Cntr ,avanced GeoenvironmentalAddress 837 Shaw Rd City Stockton Lic# EBL227 _Phone# !2091467-1006 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL!BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') $DESTRUCTION (choose type below) <br /> u SOIL BORING# n OVER-BORE. DIAMETER-8 inch/12 inch <br /> Il WELL# ILk 1-j-4 T 1r owl lw w T; VW-( I�`►r° 71 i '�wa 13 PRESSURIE GROUT <br /> *Other GROUT SPECIFICATIONS Portland V�, <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING In HOLLOW STEM DIA,OF BOREHOLE2.:.0"' MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: 2/6-inc <br /> EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: U STEEL Q PVC Q OTHER: <br /> VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: d AUGERS p HOSE <br /> p AIR SPARGE!OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 4 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> p OTHER: a OTHER APPROX.BORING DEPTH a 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 /> 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 rOrdinances, RulZ*1 <br /> Regulations, and all applicable California State Laws. /J <br /> Signed x i►�gai <br /> ��f TitlelCompany •T� <br /> Print Name r V � Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1 l <br /> 11 <br /> WORK PLAN DATED: iv , <br /> Application Accepted By Date Issued cill Area —5.6 t( <br /> Grout Inspection By Date ft ff Final Inspection By Date 9 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'O BY DATE PERMIT t SERVICE REQUEST# INVOICE <br /> �s° •'� q q j SR# / <br /> C-57-t/WCC-WAIVER— C-57 Letter of Authorization to sign permitjf!�'Encroachment doc� <br /> EHD 29-02-001 <br /> 6/22/04 <br />