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*n Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 <br /> MITIGATION <br /> 4 . <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f j <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 1601 Turnpike Road Cross Street Lincoln City Stockton Zip 95206 Parcel# 165-040-13 <br /> PROPERTY <br /> Owner LOPEZ NEREIDA P Address PO BOX 6569 City STOCKTOAT Zip 95206 Phone# (7601455-3239 <br /> C-57 Contractor maga nr;11 ;ng Address 950 Howe Ave City Ma ;ne, Zip 94553 Lic# 555407 Phone# (925)313-S800 <br /> Consultant/Sub Cntr Address av7 qh,,., Ad City Stockton Lic# Semz7 Phone# jznsia57-loos <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> O NEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER, OTHER*) G DESTRUCTION (choose type below) <br /> ESOILBORING# CPT-1,B-4,B-6,B-7 DOVER-BORE. DIAMETER <br /> G WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS:- <br /> TYPE <br /> MMENTS:'TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING G HOLLOW STEM DIA. OF BOREHOLE 2" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: NA _ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: G STEEL 0 PVC G OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL SFC-TD TREMIE TYPE TO BE USED: H AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE $PUSH POINT(GP or CPT)GROUT SEAL PUMPED: G Yes 0 No (NOTE: MAXIMUM FREE-FA/I DEPTH IS 30') <br /> 0:SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONSM,pe TT Pnrtl and <br /> G OTHER:_G OTHER APPROX. BORING DEPTH 70-180� G BOLTED TRAFFIC BOX or G STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS: EACH BORING LOCATION IS A PAIRED BORING; ON-SITE INVESTIGATION FOR LOPEZ PROPERTY. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4U 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 Ord! ncesl Is an Regulationsl and all applicable California State Laws. _ <br /> L ���1 <br /> 1 <br /> Signedx ` Title/Company Staff Scientist <br /> Print Name Al;ann rnlasT;ta Date 08/20/08 Fllf: c 02008 <br /> DEPARTMENT USE ONLY FrtMROI1NIEJT hEALTH <br /> SITE MAP IN UNIT IV FILE, ADDRESS: G D 1 Turnpike- 2 on d I'ERMi'T/SERVI0:FC <br /> WORK PLAN DATED: pp ��2 O R <br /> Application Accepted By V I P�h r ' A L !V 1 e ) P T Date Issued .2:2, ZO Area <br /> Grout Inspection By Vj Fiv['i a.n? r�i-iA-U Date 9- 3-0,' Final Inspection By �- 1 Date 9"r`0 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: T- Yi — <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 5EC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3563 35.00 404. 0 0 32 5 9/1?? 8 22 Og SR# 00 52 0 9 <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 />