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,o R y co *San Joaquin County <br /> Environmental Health DepartmentE- <br /> { 304 East Weber Avenue, 3rd Floor, Stockton, CA 9526IGATI <br /> ON <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/e��d% , <br /> �' � �� � <br /> ``"QRS` Well Permit Application X007 UNIT IV <br /> En;1V1R NIVi Lki i HLALTy <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE-_ l I <br /> _r S Fi /!CEc� <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 /> WELL LocationAssessors_ <br /> 2122 S. Airport Way Cross Street E. 8th St. City Stockton Zip 95206 Parcel# 169-162-01 <br /> PROPERTY <br /> Owner Ralph Lee White Address 2203 S. Airport Way City Stockton Zip95206 Phone# <br /> C-57 Contractor_Gregg Drilling Address 950 Howe Rd. City Martinez Zip94553 Lic#L`10i6SPhone# (983)313-5800 <br /> Consultant/Sub Cntr Advanced GeoEnvironmentai Address 837 Shaw Rd. City Stockton Lic# 680227 Phone# (209)467-1006 <br /> GIS Coordinates:X —'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> .KNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 11 SOIL BORING#CPT-1 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 2.01 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 loo' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE R PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> $SOIL BORING O HAND AUGER GROUT SPECIFICATIONS Type I/I I Portland Neat Cement <br /> 0 OTHER:_a 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County OrdinanW, Dulp4 and iZegulations, and all applicable California State Laws. <br /> Signed x Pf _A;1�7- Title/Company Vice President/ Advanced GeoEnvironemental <br /> Print Name Robert Marty Date 08 May 2007 <br /> DEPARTMENT USE ONLY FILE <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z12Z p�.�..t>_ _ tJa.,�� COPY <br /> WORK PLAN DATED: 0 -7- <br /> Application Accepted By ` L- Date Issued S/Z��C�— Area ei?t <br /> Grout Inspection By /�.�t�uw a+� Date !9-/2—q& 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 /> asp2g-S'.oa z S66s" S�zs SR <br /> /os� # 50�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 />