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y .I <br /> WELL PERMIT APPLICATION! FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNT( PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATEISSUED <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 Public Health Services,Environmental Health Division. <br /> Assessors <br /> WELL Location 9S9A WW,,h4--�_c.^ cr Cross Street Road 23 City Stockton Zip 95203 Parcel#145-030-009 <br /> PROPERTYOwner pnencF Pnwo_r Co-LP Address 7576 W- Wach;ngrnnCityStarkrnn ZipQS2n7Phone# vno�-22z8 <br /> 0-S7ContractoPrariGion SamplinaAddress 1400 So. 50th St. chyRichmondZip94804Lic1 3687 Phone# 510— 237-4575 <br /> Consultant/Sub Contractor,F,1 x u�1 ..,�1„ <br /> dress 1a�n Ogden T), Cltg, j, y�.�c# Phone#�g0_ 907-9100 <br /> GIS Coordinates:x 37.49494 ,Y —121 32567 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION D(choose <br /> Oe below) <br /> 0 SOIL BORING# SB-3 SB-4 <br /> RE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other. Grout Speciflcetions: (' r g r <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2.5 in.MULTIPLE CASINGS?BYES ONO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DYPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS o HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> I[SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH R f r. D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? _ (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed &k- Title/Company Project Geologist/Eyler & Kalinowski, Inc <br /> Print Name Britt von Thaden Date 9/12/02 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE JPERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER_, C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />