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• San Joaquin County [ E�- N <br />Environmental Health Departmen SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95fq28 0 9 'M7 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />ENVIROWENT HEALTH <br />Well Permit Application PERMIT/SERVICES <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 />WELL Location 75 East Alpine Avenue N. El Dorado at. Assessors <br />P Cross Street CityStockton Stockton Parcel# 115 - 14 0 - 07 <br />PROPERTY <br />OwnerGuido G. Segarini AddressPO Box 1810 City_Aptoa Zip95001 Phone# 831-689-9285 <br />Rancho <br />C-57 Contractor Ca s c ads Address3632 Omec Circle CityCordova Zip 95742LiC#717510 Phone#916-638-1169 <br />Consultant/Sub Cntr ETIC Engineering Address 2285 Morello Ave Pleasant <br />City624022 Phone#925-602-4710 <br />GIS Coordinates: <br />Township 02N Range 06E Section 34 <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROSE, HYDROPUNCH, HAND -AUGER, OTHER') Q DESTRUCTION (choose type below) <br />Q SOIL BORING # Q OVER -BORE. DIAMETER <br />N WELL # 3 -n+W' S Q PRESSURE GROUT <br />•Otheroha." GROUT SPECIFICATIONS <br />COMMENTS: _ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />1; MONITORING HOLLOW STEM DIA. OF BOREHOLE$! Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: 2L, __ <br />Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS Sch. 40 TYPE OF CASING: Q STEEL 8 PVC Q OTHER: <br />OVAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 27 ' TREMIE TYPE TO BE USED: 8 AUGERS Q HOSE <br />Q AIR SPARGE/ OZONE Q PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Q Yes Ig No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />aSOIL BORING '�HANDAUGER GROUT SPECIFICATIONS Neat cement grout. <br />Q OTHER:_0 OTHER APPROX. BORING DEPTH44' gBOLTED TRAFFIC BOX or Q STOVE PIPE <br />CONDUCTOR CASING PROPOSED No (if YES, list specifications in comment section) <br />1411n1�Lwlnrn Z ` 5ca�/1_¢ V"A_ec:C <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 <br />County Ordinances, Rules <br />Signed X�- <br />Print <br />SITE MAP IN UNI <br />WORK PLAN DA <br />this application and that the work will be done in accordance with San Joaquin <br />dations, and all applicable California State Laws. y� <br />Title/Company i!&;C d e D11-1111 h r . I 1 t- <br />_ _ .r.....-, <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued 2- [ I0 Area <br />Grout Inspection By 1A,\odaa a w-- Date 2- i1 t7} net Inspection By G(�_c Date 7 - <br />Destruction <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: 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 />ado ( <br />�S -�cj,o o <br />tj <br />z(f <br />SR# q <br />`� l <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 <br />6/22/04 <br />