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. r <br /> >� u �a an Joaquin County. . YMENT F11 F PY <br /> a % Environmental Health Department BF ECENE <br /> L) III W90 W <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 3 Zpp�ITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehdA,4 <br /> • 4` F Well Permit Application sAENvIRONMErT+�TvUNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEALTH OEPFRTMENT <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 Developr, nt IOtI Chapter r 9-1115.3 and the Standards off San Joaquin County Environmental Health Department. <br /> Assesso <br /> WELL Location'YI7 �dq�3iP�rN�, �111.;.—ear _ Crrooss Street�°'�5� � City Stockton Zip Parcel#r����Z� <br /> PROPERTY FGtfmrV7�io/Ir�et t r 1 r' tti5 i <br /> Owner Gloria A. Beckham Address 1131 Oxford Way City Stockton Zip CA Phone# 209-465-7138 <br /> C-57 Contractor V&W Drilling Address P.O. Box 416 Cit,Isleton Zip 95641 L1C#720904 phone# 916-777-41110 <br /> Consultant/Sub Cntr Kleinf elder, Inc. Address 2825 E. Myrtle St.City Stockton Lic# NA Phone# 209-948-1345 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> f NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> g WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ff MONITORING ItHOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 _ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: 0 STEEL H PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ff AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING OHAND AUGER GROUT SPECIFICATIONS Neat cement w/4$ Bentonite powder <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 80' 0 BOLTED TRAFFIC BOX or OSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED NA (if YES,list specifications in comment section) <br /> COMMENTS: <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 in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws,,�'__ ,�JJ <br /> Signed x Title/Company /yG.9\ C�ePX�eRf,S�L"1/OA/r'['L�� <br /> Print Name Datee <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE ADDRESS: r� ,!j/LG✓ 6 h� G' 1 <br /> WORK PLAN DATED: 2 05 !! �/ <br /> Application Accepted By Date Issued X—G—o V Area (Y <br /> Grout Inspection By Date B Final Inspection By Date <br /> Destruction Inspection By Dat Obi <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> Q 6 b'pDo /2.769 2d I t/3OM6 SR# Q ZY <br /> C-57 WC=WAIVER_ C-57 Lettteerof Authorization to sign permit_Encro ment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />