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ul <br /> o ... San Joaquin County <br /> o • - c I �r <br /> a Environmental Health Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 T TION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd ra�'1 " °�(� IV <br /> ca`;FoRN`P Well Permit Application ENiV,�;!;1I.." "` iT" <br /> P�'Q;,11T ^(:(5yfl"r:r- <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> WELLLocation 602 North California St. Cross Street Oak City Stockton Zip CA Parcel# 139-165-09 <br /> PROPERTY <br /> Owner Gary Stallworth Address 602 North California St.City Stockton Zip 95202 Phone# 209-464-1282 <br /> C-57 Contractor Mitchell Drilling Address 7900 Myrtle Ave City Eureka Zip95503 Lic#672617 Phone# 707-444-9040 <br /> Consultant/Sub Cntr Advanced Geo Environmental Address 837 Shaw Rd. Citystockton Lic# 680227 Phone# 209-467-1006 <br /> GIS Coordinates:X 'y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 13 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> $WELL# Mw-9 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 13 MONITORING g HOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_2'__ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCD 40 TYPE OF CASING: 0 STEEL R PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 56' TREMIE TYPE TO BE USED: ff AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FA// DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Type II <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 70' 0{BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NA (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4U 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 and Regulations and all applicable California State Laws. <br /> i <br /> Signed x_ Title/Company Staff Scientist/Advanced GeoEnvironmental <br /> Print Name Ally Colavita Date <br /> DEPARTMENT USE ONLY 17/ <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Coo Z C-,C1 (A-(CV1 C- <br /> WORK PLAN DATED:_ITI <br /> Application Accepted By Date Issued 1 f 3 l a Area Z <br /> Grout Inspection By I �...�,�C Date 1 3 o Final Inspection By `„ Date 3 !YAC- <br /> Destruction <br /> ODestruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 5 EC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> tcb <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 />