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o ctal )an Joaquin County FILE UPY <br /> } kF2a Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/chd UNIT IV <br /> Well Permit Application q 7 e A <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2037 FEB 15 P � " GD <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described . This appiicrntign its made m %rn <br /> copllggsawith San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health �artr�en <br /> - t <br /> 'be �l <br /> ` �, Aag s b OU� <br /> WELL Location 1201 South Center Street Cross Street French Camp City Stockton Zip Pa4" <br /> PROPERTY 3436 Admiral Drive Stockton 95209 ' <br /> Owner Robert Huckins Jr . Address City Zip.!.5209 <br /> C-57ContractorMitchell Drilling Address 7900 Myrtle Ave City, Eureka Zip 95503 Uc# 672617 Phone007 - 444 - 9040 <br /> Consultant / Sub CntrAdv GeoEnvironmental Address 837 Shaw Road City Stockton Lie# Phone# 467 - 1006 <br /> GIS Coordinates: X , Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> gNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING # 0 OVER-BORE. DIAMETER <br /> fI WELL #SVE - 1 through SVE - 6 0 PRESSURE GROUT <br /> a *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL - IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA. OF BOREHOLE8_25 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:2 - inch <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: 0 STEEL b PVC 0 OTHER: <br /> APOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1 n TREMIE TYPE TO BE USED: 13AUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes 0 No (NOTE : MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Cement <br /> 0 OTHER:.Q OTHER APPROX. BORING DEPTH 30 Feet D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NA (if YES, list specifications in comment section) <br /> COMMENTS: 6 Soil Vapor Extraction wells to 30 feet <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS . <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS- <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County OrdinanW, Igo and egulations, and all applicable California State Laws. <br /> Signed «1 SF Title/Company Vice President <br /> Print Name Robert Marty - Date 2 - 12 - 07 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED' <br /> Application Accepted By Date Issued Z� Area ✓ � <br /> Grout Inspection By 44 Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> sa SR 4V 3 <br /> C-57�.Vl' <br /> WC_-WAIVER_ C-57 Letter of ' Authorization to sign permit_ Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />