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^ ul 4tan Joaquin County 0 <br /> 0 <br /> Environmental Health Department SITE <br /> i 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 (�CF8�ATION <br /> �CEC L <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/e d IT IV <br /> Well Permit Application OCT - 9 ZUU6 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED �uICGnnI77.... <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. R i rrri9ee LTAnpliance with San <br /> Joaquin County Development Title,Chapter&1115.3 and the Standards of San Joaquin County Environmental DICES <br /> 110 E Turner Rd Stockton S Lodi 95240 Assessors <br /> WELL Location Cross Street tCity Zip Parcel# 04124048 <br /> PROPEMtre-Cal Name lat 715 S Guild St <br /> Owner P �iddress city Lodi zip 95240Phone# 800-234-6264 <br /> C-57 Contractor Precision SampliAeress 1081 Essex Ave city Zchmondp9480]Lic#636387Phone#510-237-4575 <br /> Consultant/Sub CntrGeomatrix ConsultAddress2444 Main St #21�ity FresnOLiC# Phone# 559-264-2535 <br /> GIs Coordinates:x 6340521.31 Y 2240087.16 Township T3N Range RISE Section 1 <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING 4CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 1 DESTRUCTION (choose type below) <br /> 1 SOIL BORING# 1 a OVER-BORE. DIAMETER <br /> D WELL# a PRESSURE GROUT <br /> U"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ p MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: NA _ <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: NA <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAPOttOm—TOP TREMIE TYPE TO BE USED: a AUGERS u HOSE <br /> a AIR SPARGE/OZONE 1 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 1 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Neat Cement <br /> p OTHER:_0 OTHER APPROX.BORING DEPTH 15' a 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 Ordinances,Rul s and Re lations,and all applicable California State Laws. <br /> Signed x -> � Title/Company L ��h P /' 0 <br /> Print Name 1,16 111"17 Ar Zf MVO N/ S Date o <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Pt k 14tH. )Z�l Lodi <br /> WORK PLAN DATE/D:: Lbt, <br /> CD )2f-6 <br /> Application Accepted By 6d:Lam\ Date Issued /0//1#6, Area g� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> d-C)bl M-9 j6p 0 14- SR# da'L(rp 3 <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 />