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E COPY <br /> ovate h> I 'n Joaquin County <br /> Environmental Health Department SITE <br /> r East Weber Avenue, 3rd Floor, Stockton, CA 95202 SITE <br /> PVV(4 68-3449 Fax: (209) 468-3433 Web : www. sjgov.org/ehd Cps UNIT IV <br /> I cq° '=, ,o LP <br /> f / K6R� Well Permit Application <br /> AUG 2 2 2007 <br /> -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> EN H <br /> Application ig p in County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County e� � e I , G pter 9-1115.3 and the Standards of San Joavin➢CouaontxnEnvironmental Health Department. <br /> S . Cantor St , S .Cit of Stockton Right of wa eekson St , S . commerce Assessors <br /> WELL Locationy 9 y Cross Street CitystStockton Zip Parcel# <br /> PROPERTY 3436 Admiral Drive <br /> Owner R . nc ��Jr . Address City Stockton Zip 95206 phone# <br /> C-57 Contractor Gregg Drilling Address950 Howe Ave City Martinez Zip945531_i0#656407 Phone# ( 925 ) 313 - 5800 <br /> Consultant / Sub CntrAdv GeoEnvironmental Address 837 Shaw Road City Stockton Lic# Phone# 467 - 1006 <br /> GIS Coordinates: X Y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL / BORING (CPT, GEOPROBE , HYDROPUNCH , HAND- UGER, OTHER') p DESTRUCTION (choose type below) <br /> 0 SOIL BORING # CPT - 1 through CPT - 8 / DOVER-BORE . DIAMETER <br /> 0 WELL # / n I] PRESSURE GROUT <br /> 0 *Other YY w (�' 3 GROUT SPECIFICATIONS <br /> COMMENTS : _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ------ <br /> n 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 200 ' TREMIE TYPE TO BE USED: jjAUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE PUSH POINT (GP o CPT GROUT SEAL PUMPED: p Yes p No (NOTE : MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Type II Portland <br /> 0200 'bTHER: 0 OTHER APPROX. BORING DEPTH 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 Ordinan 50ulations, and all applicable California State Laws. <br /> i <br /> Signed x lie/ <br /> � � Title/Company Vice President <br /> Print Name Robert Marty Date 08 - 21 - 07 <br /> SITE MAP IN UNIT IV FILE, ADDRESS ; DEPARTMENT USE ONLY ` <br /> WORK PLAN DATED ; <br /> Application Accepted By Date Issued ?`47W411_O1 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC' D BY DAT PERMIT / SERVICE REQUEST # INVOICE <br /> 0q zv sR# per/ azo <br /> C- 57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc 5 <br /> EHD 29-02-001 rT <br /> C,, ' I`.1 !i <br /> „ I <br /> 6/22/04 I ; . l Ii 7/0,35 <br /> l.� L •3 1 �I p It] P <br />