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WELL PERMIT APPLICATION FOILECFVJ�,--� <br />PE CODES <br />SAN JOAQUIN COUNTY IGATION <br />1-11- <br />3NT <br />AMOUNT REMITTED <br />M"jNVIRONMENTAL HEALTH DEPARTMENT (EHDr <br />`IV <br />REC'D BY <br />04 E. Weber, Third Floor, Stockton, CA., 95ZVIP(Jf4MENT HEAT JH <br />INVOICE <br />(209) 468-3449 PF-KAIT/SERVICES <br />NON-REFUNDABLE PERMIT EXPRES 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 />SR# oo4.7400 <br />Joaquin County Development Title, Chapter 91115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location 3333 West Hammer Lane Cross Street Mariners Dr City Stockton Zip 95219 Parcel# 071-180-14 <br />PROPERTY Owner Gil Wymond Address PO Box 380 City Riverbank Zip 95367 Phone# <br />C-57 Contractor—Resonant Sonic -Address- 220 N. East Street City Woodland Zip Lic# 802334 Phone# (530) 668-2424 <br />Consultant/ Sub CntrATC Associates_ Address_ 6602 Owens Drive, Suite 100_City Pleasanton CA Lic# Phone c 2.j /G 0-9 3&0 <br />GIS Coordinates: X Y Township Range Section <br />,V <br />WORK TO BE PERFORMED <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HANDAUGER, OTHER') [x] DESTRUCTION (choose type below) <br />SOIL BORING # [x] OVER -BORE. DIAMETER 8 <br />0 WELL # 0 PRESSURE GROUT <br />0 "Other GROUT SPBFICATIONS: Tremie <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ✓ n <br />[x] MONITORING 0 HOLLOW STEM DIA. OF BOREHOL ,,Ot % 0" MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2_ <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: [x] OTHER destruction APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 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, Rules and Regulations, and all applicable California State Laws. <br />Signed x TitleiCompany <br />Print Na e �o`�C ��� r� �o -� c Cr t '' Date ZZ20/cc <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: , 5 .5- VV c6 f Iqa m rn, e- r ,LQ n S}o (,k io r, , CA <br />WORK PLAN DATED: ,,JU I t/ 3 o(& <br />Application Accepted By Y i oa rY ,G L. I `Acca rf n e v) Date Issued JU 1!/ 3 2-006 Area I +s9 <br />Grout Inspection By l Date I 7&Il a Z Final Inspection By Y<<+u^r /Q�('� Date L d 4 <br />Destruction Inspection By V,�-,+4-& - i, )JIAIf!7/ <br />Date .25-10 6 <br />COMMENTS / CONDITIONS: Des t r u C f: a a n+ <br />ner <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />SR# oo4.7400 <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc 9/30/02 <br />