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/�p,GUrry\ y <br /> °o\ Ulan Joaquin County <br /> -; 53 Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> ).468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd MITIGATION <br /> UNIT IV <br /> Well Permit Application <br /> eY ' FUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hem,� rvJoaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County I7nY Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location_2651 South Airport Wa Assessors <br /> Cross Street Tenth City Stockton Zip 95206 :� Parcel# 16912003 <br /> PROPERTY <br /> Owner Earthgrains Bakin.2 Co. Address 2651 S. Airport Way City Stockton Zip 95206 Phone# 209-547-2202 <br /> C-57 Contractor Grego Drilling Atltlress 950 Howe Road C57485165 <br /> Cityhlartinez Zip 94553Lic# :Phone,R 925-313-5800 <br /> e <br /> Consultant/Sub Cntr PSC Address210 W. Sand Bank Rd.City Columbia Lic# Phone# 618-281-7173 <br /> GIS Coordinates:X ,Y.,Towns hi 1 North <br /> _ p Range 6 East Section 22 and 23 <br /> WORK TO BE PERFORMED: - <br /> IFNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH, HAND AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> If SOIL BORING# CPT,-'4 through CPT-7 a OVER-BORE. DIAMETER <br /> 0 WELL# <br /> 0`Other 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> '--COMMENTS-. R u� PT tion nps-and`uo o Zn a� o.,+ hydroounch bo "ns <br /> - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE2'! 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 II <br /> 0 AIR SPARGE/OZONE IFPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> JESOIL BORING p HAND AUGER GROUT SPECIFICATIONS Neat cement <br /> 0 OTHER: _ 0 OTHER APPROX.BORING DEPTH 100' 0 BOLTED TRAFFICBOXor 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <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 Rules a d Regulations, and all applicable California State Laws. <br /> Signed u.✓rTitle/Company Project Manager <br /> Print Name Paul Anderson - Date 3 d4 Zea <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 26 St S A IN f2, W G <br /> WORK PLAN DATED: <br /> 4 � <br /> Application Accepted Byd��t i� � —r�,"•`i� Date Issue3--,zo - 0 $ Ar.. 14 s <br /> Grout Inspection By )(ff 4zhic;A Me- Ca I- 1L/<" Data 4- I Final Inspection By ate 4-9`-03— <br /> Destruction <br /> T-9=0 SDestruction Inspection By Date <br /> COMMENTS/CONDITIONS: CP 4:P7=REQUEST# <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE 350 / 89. 00 , b9U0 99369ro68o �2 3-ZO-aB <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 WEB 1 <br /> 9/11/2007 <br /> i <br />