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SAN JOAQUIN COUNTY <br /> ' = ENVIRONMENTAL HEALTH DEPARTMENT <br /> `�• SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE <br /> .. Telephone:{209)468 454 Fax:{209)468-3433 Web.www.si9ou.org/ehd <br /> ::w•,• UNIT"IV <br /> WELL PERMIT APPLICATION <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquln 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 /> Callrana Stockton Yerd On South 8 Street betwaen 95201 Assessor's <br /> Well Location tntenence Statlon Cross Street _411h Street and charter Way City Stockton Zip Parcel# 171.095ZB <br /> Property Ca¢rens <br /> Owner Address 1604 south a street Clfy Stockton Zip 95201 Phone# 209.948.7820 <br /> C47 Contractor w <br /> Gregg DnIIin9&Testtnp Inc, 95D Howe Road Martinez 94553 9253435800 <br /> Address City Zip Lie# 4115165 Phone <br /> AMECC,eomafrix 10570 hite Rock Road,Suite 1DD cit one Rancho Cordova ZIP 95673 Ph9165363200 <br /> Consultant/Sub Cntr Address y • <br /> GIS Coordinates:X YTa. <br /> Township Range Section <br /> WORK TO IBE PERFORMED: <br /> ZI NEW WELUBORING(CPT.GEOPROBE.HYDROPUNCH.HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW} <br /> 7x]SOIL BORING# CPT-1,ca7-2,CPT-3,CPr-4 <br /> I]WELL# AS-I.Owl,ow-z OW-3 ❑OVER-BORE DIAMETER <br /> ❑ <br /> ❑"OTHER PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> El EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 91 MONITORING ®HOLLOW STEM DIA.OF BOREHOLE rmn 0 MULTIPLE CASINGS❑MULTI-LEVEL WELLCASING D)A:" L'• <br /> ❑EXTRACTION F-1 AIR HAMMER/DRIVEN CASING THICKNESS SCH40 TYPE OF CASING:❑STEEL 21 PVC ❑ OTHER <br /> ❑VAPOR E3 MUD ROTARY DEPTH OF GROUT SEAL 3oft69a TREMIE TYPE TO BE USED!I AUGERS❑HOSE <br /> ®AIR SPARGE/OZONE I91 PUSH POINT(GP OR CPT)„_GROUT SEAL PUMPED:®Yes ©No(NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 29 SOIL BORING EI HAND AUGER GROUT SPECIFICATIONS neetcement,3.5%Sentorite <br /> ❑OTHER: ❑OTHER; APPROX.BORING DEPTH45flbys(wells)/80 t(CPTs) I&I BOLTED TRAFFIC BOX OR L7 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED pfYES,Istspecifications incommentsection) _..-. <br /> . <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 1 accordance with San Joaquin County Ordinances,Rules and <br /> Reggtatlons,and all applicable Californla Laws. <br /> Signed SeNorFr4ineer/AMEOGeometrix <br /> Print Npme Scoff W.Farbeas.PE Date <br /> DEPARTMENT USE O L <br /> SITE MAP 1N UNIT IV FILE,ADDRESS: --U2-04 �j E , 4 G I <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED 13Y DTE ISSUED AREA <br /> GROUT INSPECTION BY LAM ,A 1.t z O FINAL INSPECTION BY DATE 1 u <br /> DESTRUCTION INSPECTION BY DATE <br /> CONIMENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# - <br /> PE'CODES FEE INFO AMT REMI I CHECK# RECV'D BY. DATE' PERMITISERVICE# INVOIPE,.• <br /> 3 5-03 y3�"oo y f io SR#,Sl 68 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT. ENCROACHMENT DOC <br /> EHD 2"1 10/28/08 WELL PERMIT APP <br />