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San Joaquin County <br /> Environental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <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 /> �V- S-h 8536 Aarcel#r'Afl-38 <br /> WELL Location 730 7-d�s'r;Af Av�EAct t i VE) Cross Street City PiPON Zip o ParceHF_ 0_6 <br /> PROPERTY <br /> Owner AVID . L. SANDERS Address F-0, 130)( 365' City_ELLi 014 Zip_6366 Phone# <br /> C-57 Contractor 6RE66 Dr;li:rd6T -,address 950 Howe Rd. 22City AR¢Tj'yn Zip 94553 Lie#65640 Phone# 9ZS-7�z-Sgc� <br /> Consultant l Sub Cntr I��MAtr�z (o.,tdl1Auh Address Zi31 wessrF2 Cd, Ih'.lr City c# Phone# 310-b/s3-�/L a0 <br /> GIS Coordinates:X /34 b 3I a0m ,Y ±l 1516160 n, Township Range Section <br /> LAT. 3�,yN lZN CON: /Z),' 19VV <br /> WORK TO BE PERFORMED: <br /> %NEW WELL I BORINGCPT,GEOPROBE, YDROPUNC HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# p OVER-BORE. DIAMETER <br /> p WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: 1� 4o S CPT bore �t = �0 T'-er 6111, q to 8 lWr�,w rA — )641r 51oE W SN/uti w/ Ave._ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 11 MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC 0 OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE"PUSH POINT(GP or-OPROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )KSOIL BORING a HAND AUGER GROUT SPECIFICATIONS A- W lv-,f tor„n.F jrcot _ <br /> U OTHER: fl OTHER APPROX.BORING DEPTH__70 !eet U 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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, RulesandRegulations, and all applicable California State Laws. <br /> Signed x S14aa�f C4.. Y— TitlelCompany fro1 e'& <br /> Print Name �FGP/�^�'�A'�.� tr Date 4j115/0� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD ESS: T /a C Q <br /> WORK PLAN DATED: 1 Ij 13 a; <br /> Application Accepted By Date Issued 1 �2 l I I 5 Area y <br /> Grout Inspection By `I✓) . &K j tnIF DateITS OS Final Inspection By Date <br /> Destruction Inspection By Date <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 /> X16 ( 1� �� X1 01 1 sR# �{ 5oas <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 />