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At,r ,� 1San Joaquin County <br /> 2 z Environmental Health Department SITE <br /> =t � „(Ir, O E. Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209 4$8-3449 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 <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 /> 853 E. Yosemite Ave. Pssessors <br /> WELL Location Cross Street Powers Ave.AV@. City Manteca Zip 95336 Parcel# 223-32-015 <br /> PROPERTY <br /> Owner 7-Eleven, Inc. Address P.O. Box 711 city Dallas Zip 75221 Phone# <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road city Martinez Zip 94553Lic#48f45'Phone#925-313-5800 <br /> Consultant/Sub Cntr SECOR Ent., Inc. Address 3017 Kilgore Road City Ran!hOc0rdOvaLic# 'hone# 916-861-0400 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERF D: <br /> 0 NEW WELLBORIN (CPT EOPROBE YDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL B G1 rP` 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N//- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 30TREMIE TYPE TO BE USED: s 0 HOSE <br /> 0 AIR SPARGE/OZONE +PUSH POINT GP r CPT)GROUT SEAL PUMPED: 0 Yes ONo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301` <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /Ne.vt ce wee,n.'t <br /> 0 OTHER: []OTHER APPROX.BORING DEPTH J r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Nd (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 pr pared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi d Re ons, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name /• /� �//� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD SSK-3 f--- , OULX-��. L v P S e <br /> WORK PLAN DATED: Z 0 <br /> Application Accepted 13 Date Issued P I Area <br /> Grout Inspection B Date/oh(-/ Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: O 775 kiitins 4nC b•n <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 3s-a 51- — ( j 14c- h SR# [�d�l S T3 <br /> C-57_ WC__,y_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 <br />