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0 San Joaquin County WAE�1 v En <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95PPB 0 9X00( MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />ENVIRONMENT HEALTH <br />Well Permit Application PERMIT/SERVICES <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE <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 />N. E1 Dorado St. Assessors <br />WELL Location East Alpine Avenue Cross Street City Stockton Zip95204 Parcel#115-140-06 <br />PROPERTY <br />Owner Arthur Lavagnino Address1466 W. Magill Ave.City Fresno Zip93711 Phone# 559-431-4312 <br />Rancho <br />C-57 Contractor Cascade Address3632 Omec Circle City Cordova Zip 95742Lic#717510 Phone#916-638-1169 <br />Pleasant 624022 <br />Consultant/ Sub Cntr ETIC Engineering Address 2285 Morello Ave CityNi}} Lic# Phone#925-602-4710 <br />GIS Coordinates: X ,Y ,Township 02N Range 06E Section 34 <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # u OVER -BORE. DIAMETER <br />8 WELL# 2 0 PRESSURE GROUT <br />V*Other Q _ ,a FcrI_ma GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />It MONITORING 9 HOLLOW STEM DIA. OF BOREHOLEg= 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: �L- <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sch. 40 TYPE OF CASING: 0 STEEL 8 PVC BOTHER: <br />fVAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 27 ' TREMIE TYPE TO BE USED: B AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 5 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />a SOIL BORING g#IANDAUGER GROUT SPECIFICATIONS Neat cement grout. <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH44 ' If BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED No (if YES, list specifications in comment section) <br />.1 / • •• / / • / f /I/ • .Q 1-1 _ J <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT O'R ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have <br />County Ordinances, Rules <br />Signed <br />Print <br />SITE MAP IN UNIT IV FILE, <br />WORK PLAN DATED: tC <br />this application and that the work will be done in accordance with San Joaquin <br />dations, and all applicable California State Laws. <br />DEPARTMENT USE ONLY <br />-+ s f ,tA_an't R fS 3­(-� <br />i t <br />Application Accepted ByDate Issued 1 O�Area <br />Grout Inspection By i,A�� Date_LiO Final Inspection By '%%r yr ritco✓v Date Z '2zO <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT I SERVICE REQUEST # <br />INVOICE <br />ZZz`i-T <br />/ <br />2_ 1510 <br />SR# -l-\ `ltL� <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />ERD 29-02-001 <br />6/22/04 <br />