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9 0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT SITE <br />�C 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNIT IV <br />AIS' 0 5 2008 WELL PERMIT APPLICATION <br />r-nlVlf�OfdP,�cN'sIiF'A�7ON�I <br />rt�:cr.(yrrtX:f-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 />Well Location 3300 N. El Dorado St. Cross Street E. Alpine Ave. <br />Properrt <br />Owner �1}� e-� S7"u�G7vh Address <br />Assessor's <br />City Stockton Zip 94204 Parcel# 115-153-09 <br />City Stockton <br />C-57 Contractor Precision Address 1081 Essex Ave. City Richmond <br />Consultant(Sub Cntr ETIC Engineering Address 2285 Morello Ave. City Pleasant Hill <br />GIS Coordinates: X , Y , Township <br />WORK TO BE PERFORMED: <br />® NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />® SOIL BORING# 3 <br />❑ WELL# <br />❑ *OTHER <br />02N <br />Zip Phone # <br />Lic#103437 <br />?hone 510-237-4575 <br />Lic# 624022 Phone 925-602-4710 <br />Range 06E Section 34 <br />❑ DESTRUCTION(CHOOSE TYPE BELOW) <br />❑ OVER -BORE DIAMETER <br />❑ PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />❑ EXTRACTION ❑ AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br />❑ AIR SPARGE/OZONE ® PUSH POINT (GP OR CPT) -SPT GROUT SEAL PUMPED: ❑ Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />129 SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS/0" -f r�l 2* <br />❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH max. 120 feet ❑ BOLTED TRAFFIC BOX OR []STOVEPIPE <br />CONDUCTOR CASING PROPOSED NO (if YES, list spe flailions in comment section) <br />Signed _ <br />Print Name <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules <br />applicable California Laws. <br />Title/Company <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: }S E• Gi�.To.t.,,_.t (L W CR C ►3. <br />WORK PLAN <br />r <br />APPLICATION ACCEPTED BY • �Mnntrn.� DATE ISSUED <br />GROUT INSPECTION BY p01'� FINAL INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />DATE <br />AREA <br />DATE <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # RECV'D BY <br />DATE <br />PERMITISERVICE # <br />INVOICE <br />Z�jt�1 <br />81,&C, <br />1 ZSs ?-d A.19 <br />I `SffY/09 <br />1 SR#SS 131 <br />G-57 WC <br />EHD 29-01 11/5N7 (WEB) <br />CTi7:1lYl�:�eFi1\M#Igie]y:lg1,N7:1t/_U[elJ[eL9[e]P\LR iSll1��.[N:Ie7c[tlCIr17.IBrIeIN <br />WELL PERMIT APP <br />