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/Q G\ San Joaquin County <br /> z ti, Environmental 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 <br /> UNIT IV <br /> � Z- <br /> J} JI1c�`.` ' '.v�P Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby ade to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> m <br /> 'Joaquin'County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 1444 S. Lincoln St. Cross Street W Charter Way City Stockton Zip 95206 Parcel# 16503005 <br /> PROPERTY <br /> OwnerAddress -5 CityE�� •eZip'b'Q51 b Phone#f6�_ <br /> C-57 Contractor Enprob Address P.O.Box 6093 City Oroville ip95966 Lic#777007 Phone#(530)589-2019 <br /> Consultant/Sub Cntr ETIC Engineering, Inc. Address 2285 Morello Ave. City Pleasant Hill Lic# 624022 Phone# (925)602-4710 <br /> GIS Coordinates:X -121.293579 Y 37.936946 ­Township 1 North Range 6 East Section 15 <br /> WORK TO BE PERFORMED: <br /> '%NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 'gSOIL BORING# 11— \3 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 3" 0 MULTIPLE CASINGS 0 MULTI-LEVEL 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 DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE %PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Neat cement <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 55 ft.bgs 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 nces, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> 1�ZxrY•5 \� \ <br /> Print Name Date 1 as� rC <br /> DEPARTMENT USE ONLY L <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ilf T Ll%'' `�'l� h, C- <br /> WORK PLAN DATED: f� <br /> Application Accepted By /'Y Date Issued Area / <br /> Grout Inspection By Date 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/SERVICE REQUEST# INVOICE <br /> 'I <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 />