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0 0 <br />SAN JOAQUIN COUNTY <br />ELD ENVIRONMENTAL HEALTH DEPARTMENT SITE <br />600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />`0GFelephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNIT IV <br />ENI/fl tONls ENI HEALTH WELL PERMIT APPLICATION <br />PERMIT/SERVICES 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 />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION <br />0 VAPOR <br />❑ AIR SPARGFJOZONE <br />PS SOIL BORING <br />❑ OTHER: <br />0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC 0 OTHER _ <br />❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ❑ AUGERS 0 HOSE <br />® PUSH POINT (GP OR CPT) -SPT GROUT SEAL PUMPED: ❑ Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 HAND AUGER <br />❑ OTHER: <br />GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH a"- 120 feet 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED No (if YES. list sperms®tions In mmment section) <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 I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all applicattle California Laws. <br />Signed _ <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />IrWOR1011:1w_\N <br />Title/Company <br />DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED BY (n )r o ` DATE ISSUED EA <br />GROUT INSPECTION BY IA�OAA^cr� FINAL INSPECTION BY C;— C;—_D <br />DESTRUCTION INSPECTION BY DATE 14i <br />COMM E NTSICO N DITIONS: <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />Well Location East Alpine Avenue <br />�� P <br />Cf055 Street 81 Dorado Street <br />City <br />Stockton Zip 54204 Pafcel# 115-140-06 <br />Parcel 1 <br />Property <br />PERMIT/SERVICE # <br />INVOICE <br />ILOW <br />Owner Arthur Lavagnino <br />Address 1466 N. Magill Ave. <br />City <br />Fresno Zip 93711 Phone# 559-431-4312 <br />C-57 Contractor Precision <br />Address 1081 Essex Ave. <br />City <br />Richmond Lic#�Ohone 510-237-4575 <br />Consultant/Sub Cntr ETIC Engineering <br />Address 2285 Morello Ave. <br />City <br />Pleasant Hill Lic# 624022 Phone 925-602-4710 <br />GIS Coordinates: X <br />, Y _,Township <br />02N Range 06E Section 34 <br />WORK TO BE PERFORMED: <br />99 NEW WELLIBORING (CPT, GEOPROBE, <br />HYDROPUNCH, HAND -AUGER, OTHER-) <br />❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />IM SOIL BORING# 2 <br />❑ OVER -BORE DIAMETER <br />❑ WELL# <br />❑ PRESSURE GROUT <br />❑ *OTHER <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION <br />0 VAPOR <br />❑ AIR SPARGFJOZONE <br />PS SOIL BORING <br />❑ OTHER: <br />0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC 0 OTHER _ <br />❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ❑ AUGERS 0 HOSE <br />® PUSH POINT (GP OR CPT) -SPT GROUT SEAL PUMPED: ❑ Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 HAND AUGER <br />❑ OTHER: <br />GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH a"- 120 feet 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED No (if YES. list sperms®tions In mmment section) <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 I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all applicattle California Laws. <br />Signed _ <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />IrWOR1011:1w_\N <br />Title/Company <br />DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED BY (n )r o ` DATE ISSUED EA <br />GROUT INSPECTION BY IA�OAA^cr� FINAL INSPECTION BY C;— C;—_D <br />DESTRUCTION INSPECTION BY DATE 14i <br />COMM E NTSICO N DITIONS: <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK* <br />RECV'D BY <br />DATE <br />PERMIT/SERVICE # <br />INVOICE <br />ILOW <br />$ set, on <br />7'e!; 0 <br />%/ <br />e 1'f lliv8 <br />SR# 5-5-130 <br />C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />EHD 2&01 11/5N7 (WEB) WELL PERMIT APP <br />