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s " in Joaquin CountyFil <br /> My <br /> La Pq <br /> R )O•_ <br /> 7-- <br /> g <br /> Enviro.. ,nental Health Department SITE <br /> M ^ 4 ast Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> N=3449 Fax: (209) 468-3433 Web: www .sjgov.org/ehd C/ : UNIT IV <br /> � rFORA Well Permit Application <br /> AUG 2 2 2007 <br /> ��ppI� �I �Drr�� I�N�O{�N-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is heYAd mddbllji) ivrj n) unty for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County De M4Ty$@RAG@i$r 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, <br /> 1113 S . E1 Dorado St E . Jackson St Assessors <br /> WELL Location Cross Street City Stockton Zip Parcel# 147 - 190 - 07 <br /> PROPERTY <br /> Owner Richard Northcutt Address3547 Bluelake Circle City Stockton Zip 95206 Phone# <br /> C-57 Contractor Gregg Drilling Address950 Howe Ave City Martinez Zip94553 Lic#656407 Phone# ( 925 ) 313 - 5800 <br /> Consultant / Sub CnVAdv GeoEnvironmental Address837 Shaw Road City Stockton Lic# Phone# 467 - 1006 <br /> GIS Coordinates: X , Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL I BORING (CPT, GEOPROBE , HYDROPUNCH, HAND-AUGER, OTHER") p DESTRUCTION (choose type below) <br /> U SOIL BORING # CPT - 9 O 0 OVER-BORE . DIAMETER <br /> 0 WELL # 0 PRESSURE GROUT <br /> g `Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STE40 DIA. OF BOREHOLE 2 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ------ <br /> 0 <br /> ___ _0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC U OTHER: <br /> 0 VAPOR 0 MUD ROTARYEPTH OF GROUT SEAL 200 ' TREMIE TYPE TO BE USED: )DAUGERS 0 HOSE <br /> g AIR SPARGE/ OZONE PUSH POINT (GP o PT ROUT SEAL PUMPED: p Yes 0 No ( NOTE : MAXIMUM FREE-FALL DEPTH IS 30 ') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS Type II Portland <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH 200 ' 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 Ordirl P <br /> yuly4and lZegulations, and all applicable California State Laws , <br /> Signedx Title/Company Vice President <br /> Print Name Robert Marty Date 08 - 21 - 07 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : ,eu s• <br /> WORK PLAN DATED : 1 9 <br /> Application Accepted By Date Issued Arep <br /> Grout Inspection ByDq,) -v _Final Inspection B " ' Date I <br /> Destruction Inspection By f Date <br /> COMMENTS / CONDITIONS : <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC' D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> z 383. r 2� 0 3 S y SR# <br /> C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit Encro ment doc <br /> EHD 29-02-001 I <br /> 6/22/04 r) <br /> �. l i : Ir <br />