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•' WELL PERMIT APPLICATION F0� E,�� <br /> SAN JOAQUIN COUNTY IyIGATION <br /> 3 <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EH DrIf it U T IV <br /> � � �f0�j04 E. Weber, Thi(209) 468 3449 ton, CA., 95PVERtMIRONTJSERVICESENT Tu <br /> UU (( NON-REFUNDABLE PERMIT EXPRES 1 YEAR FROM DATE ISSUED f <br /> I 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 /> I•. Joaquin County Development Title,Chapter 91115.3 and the Standards of San Joaquin County Environmental Health Department.Assessors I <br /> WELL Location 3333 West Hammer Lane Cross Street Mariners Or City Stockton Zip 95219 Parcel# 071-180-14 <br /> PROPERTY OwnerGil Wvmond Address POBox380 City Riverbank Zip 95367 Phone# <br /> C-57 Contractor_Resonant Sonic-Address 220 N. East Street_City­Woodland Zip Lic# 802334 Phone# (530)668-2424 <br /> Consultant/Sub Cntr ATC Associates_Address_6602 Owens Drive, Suite 100_City Pleasanton CA Lir# Phon444f7-5360 <br /> GIS Coordinates:X ,Y ' ,Township Range Section <br /> i <br /> WORK TO BE PERFORMED lai <br /> 0 NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HANDAUGER,OTHER") [x]DESTRUCTION (choose type below) <br /> 0 SOIL BORING# [x]OVER-BORE.DIAMETER 8_ <br /> a WELL# O PRESSURE GROUT <br /> 0.Other GROUT SPHBCATIONS: Tremie i <br /> COMMENTS: <br /> 1 <br /> TYPE OF WELL INSTALLATION TYPE i'• CONSTRUCTION SPECIFICATIONS VM 7 j yg/DG <br /> [x]MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE�IF�p MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL _ TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER �. GROUT SPECIFICATIONS - <br /> 0 OTHER: fx]OTHER destruction APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> • CONDUCTOR CASING PROPOSED (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 Ordin aces, Ru Regulations, and all applicable CaliforniaStateLaws. <br /> Signed x �\ - Title/Company Ste= Sc it -�ciC IC' <br /> Pdnt Na a� Date /p/off <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3,555 WeSf flQmrne�r k477e iiSbGk6 x, 4 (,, - <br /> WORK PLAN DATED: July 3 120(94 <br /> Application Accepted By VI da-r^`n L Me(adne-ti Date Issued�y� 12-006. Area 1+5q <br /> Grout Inspection By � 6y"� Dale Final Inspection By 1�i� u^r1Q�(]QtTDate L OL <br /> Destruction Inspection By i Li'hr1a IlAt lI Date %? 1 y <br /> COMMENTS I CONDITIONS: Dn - I ep'e <br /> ACCOUNTING ONLY: AID# FAC# if <br /> PE CODES I.IFEEINFO AMOUNT REMITTED CHECK# REC'D BY FDATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3"2- o I sR# po47400 <br /> C-57_ WC_WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br /> r - <br />