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San Joaquin County h77Z <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor,Stockton,CA 95202 NOV 1 6tII�NG('�ATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.�gov.org/chd <br /> ENVIRONMENT HEKt1LINT IV <br /> P Well Permit Application PERMIT/SES-- <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. /7C�,�)-7 <br /> Assessors <br /> WELL Location 4444 North Pershing Ave. Cross SVeetRosemarie La.Citystockton zip 98207 ParceM 7- <br /> PROPERTY Fc;el,i <br /> OwnerEdna I. F -1+7T Address3225 Allston WayCity Stockton zip 95204 Phone# <br /> c-67 ContractorVi ronex Address5292 Pacheco Blvd.CitypachecoZip94553Lic#20&g2-'7phem# (925)521-1494 <br /> Pleasant 624022 -4710 <br /> Consultant/Sub Cntr ETIC Engineering— Address 2285 M 11 A City �1 Lic# Phone# (925)602 <br /> GIS Coordinates:X ,V ,Township 02N Range 069 Section 20 <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING JCPT C�EOPRODE;HYp.ROPUNCH.HAND-AUGER,OTHER') p DESTRUCTION (choose typebelow) <br /> `$SOIL BORING# CT615 r'j Erb) DOVER-BORE. DIAMETER <br /> EWELL# 5 soil vapor wells aPRESSURE GROUT <br /> [I'Otho GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 4" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:0.25" ,xZ <br /> g EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS 0-035 0 TYPE OF CASING: 11 STEEL a PVC B OTHER: 4Z <br /> fl a <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL See ttached_TREMIE.7YPE TO BE USED: g AUGERS 0 HOSE <br /> D AIR SPARGE!OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING §HAND AUGER GROUT SPECIFICATIONS Neat cement grout. <br /> 0 OTHER,—0 OTHEP.. APPROX,BORING DEPTH 6 BOLTED TRAFFIC BOX or g STOVE PIPE <br /> CONDUCTOR CASING PROPOSED No (if YES,list specifications in comment section) <br /> COMMENTS: vapor monitoring walla <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. GT <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 Ord- ces,Rules an e//g��u�llya��t�iio,,n��s,ffaaLnd all applicable California State Laws.,/� ^ �/ <br /> Signedx �f U'Vr x�l�U[..``t Title/Company 0 t v `i�` a,{i�C1t r'Ire��1��I nom}` <br /> Print Name a "1. � ` ' Date ' ' <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Yyyy /.rpt S L1.—r s ` Lae `' a Z3 ( J go;-2-(p <br /> WORK PLAN DATED:: ���1ppG✓��t-�� 2-��-7 U / <br /> Application Accepted ey.M�^'""'" ,_. .[ pale lssued�ll7/� Area 4 7 <br /> Grout Inspection By .Data.�Z�4 f(*7 Final Inspection By Date <br /> Destrucdon Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 8`I 8� r�SSI[v µlm rr y-I Itj SR#C9� <br /> C-57_ WC=WAIVER_ G-57 Letter of Authorization to sigh permit_Encroachment doc_ <br /> PRO 29-02-001 <br /> 6122104 <br />