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0 <br />RIECE�V no S <br />tNVIRO MA NTAOLAQUIN HEALTHOUNTY DEPARTMENT SITE <br />AU ri lekAone6( 09) 468-3449 Fax. (209) 600 East Main Street, t8-3433 Web: wwws.gov.org/ehd on, CA 95202-3029 MITIGATION <br />UNIT IV <br />ENViRIJi\'i21EN- HEALTH <br />PERMITS q.,. 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 />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />Assessors <br />Well Location tJ Haat Alpine Avenue <br />CWSS Street El Dorado Street <br />City <br />Stockton 94204 <br />Zip Parcel# 115-140-07 <br />Property <br />❑ VAPOR <br />❑ MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br />Owner Guido D. Segarini <br />Address PO Box 1910 <br />City <br />Aptos Zip 955001 Phone# 831-689-9285 <br />❑ HAND AUGER <br />C-57 Contractor Precision <br />Address 1081 Essex Ave. <br />City <br />Richmond Lic# (oAdj1hone 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 />M NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />M SOIL BORING# 1 <br />❑ OVER -BORE DIAMETER <br />❑ WELL # <br />❑ PRESSURE GROUT <br />❑ -OTHER <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING <br />❑ HOLLOW STEM <br />DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _ <br />❑ EXTRACTION <br />❑ AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ VAPOR <br />❑ MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br />❑ AIR SPARGE/OZONE <br />® PUSH POINT (GP OR CPT) -SPT <br />GROUT SEAL PUMPED: ❑ Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />29 SOIL BORING <br />❑ HAND AUGER <br />GROUT SPECIFICATIONS ��Oi. Tl �iYLtF VI <br />❑ OTHER: <br />❑ OTHER: <br />APPROX. BORING DEPTH max. 120 feet ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />^ r <br />CONDUCTOR CASING PROPOSED No (if YES, list spetlficationa 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, ew4-Q applicable California Laws. <br />Signed ryf Title/Company <br />Print Name ih' 1 t�,l!% ri� <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN <br />APPLICATION ACCEPTED BY L j�DATE ISSUED O EA <br />GROUT INSPECTION BY I.(IAAA C9,4, FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECTION BY <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 />i o t <br />04"•&0 <br />-Z-T5S }o &C <br />I g t y o5- <br />I SR# 55 i <br />C-5 <br />EHD 29-01 11/5/07 (WEB) <br />I IUry I V JIUry rCKml I <br />CNL:KVAGHMtNI UL)U <br />WELL PERMIT APP <br />