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San Joaquin County <br />C �[ <br />�z Environmental Health Department[ ��� ��/ � ----11 SITE <br />61 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202=1-IGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/cY ?005UNIT IV <br />Qc�FORa Well Permit Application L ��- <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU ON ENT HEALTH <br />/'SERVICES <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 />Assessors <br />WELL Location 1081 W. Mendocino Cross Street Pershing City Stockton Zip 95202 Parcel# 113-140-02 <br />PROPERTY <br />Owner lJ of the Pacific Address 3601 Pacific Ave <br />Stockton Zip 95202Phone# 209-946-2541 <br />C-57 Contractor -eAddress C,�O /!�G(.L� City oV / - ip� c# 4hone# far- J�'/21`f <br />Consultant / Sub Cntr ESA Address 225 Bush St#1700City SF Lic# Phone# 415-896-5900 <br />GIS Coordinates: X 2178929.0 Y 6327311.3 Township � 2N Range 6E Section 6 -. <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING <br />0 SOIL BORING # <br />0 WELL # <br />0 *Other <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />STRUCTION (choose type below) <br />OVER -BORE. DIAMETER 6.5 <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS: Wells are pre -packed in 2.5" borings - overdrill using 6.5" HSA <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 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: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER 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 />J <br />C <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordina ce R es and Remulations, and all applicable California State Laws. <br />Signed x Title/Company�&7/gA—r zyoa, per' <br />Print Name Date <br />SITE MAP IN UNIT IV FILE, <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS <br />DEPARTMENT USE ONLY <br />1nRr W FYI �"— <br />Date j - J& -C, S <br />Date Issued S/4(/ S Area <br />Inspection By Date <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P QUEST # <br />INVOICE <br />3eS <br />(Q� <br />;�C� <br />X13 <br />Sal U SRI,�)gz1'7 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encron i 1 tcToc_ <br />EHD 29-02-001 <br />6/22/04 <br />