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I <br /> pq�ly �o (' San Joaquin fou t Cb-dL�D <br /> Environmental Heaj;t Depart 3 SITE <br /> 600 East Main Street, Stockton, CA 9520f2 J L��B <br /> s MITIGATION <br /> (209)468-3449 Fax (209)468-3433 Web: wvingg">WbMHEALTH <br /> Well Permit Application PERMIT/SERVICESUNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O N <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 1717 South Center Street Cross Street W 3rdSt. City Stockton Zip 95206 Parcel# 765-077-78 <br /> PROPERTY <br /> Owner Ismael Rivera Address 1717 South Center St City Stnrktcin Zip 95706 Phone# 209-462-3474 <br /> .. <br /> fi C-57 Contractor Gregg Drilling Address 950 Howe Road City C57485165 <br /> Martinez. Zip 94533Lic# . Phone# 925-313-5800 <br /> ! <br /> Consultant/Sub Cnnttrr PSC Address/210 W. Sand Bank Rd City Columbia Lic# Phone# 618-281-1543 <br /> I! GIS Coordinates:X J�.�35 .Y-)Z) 2$S� ,Township 1 N Range 6E Section 14 ` <br /> !I WORK TO BE PERFORMED: <br /> a NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# �., p OVER-BORE. DIAMETER <br /> WELL# MW-4N amen Mw-SA - p PRESSURE GROUT <br /> p*Other - GROUT SPECIFICATIONS <br /> COMMENTS: ' <br /> 1 <br /> I TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS - <br /> ' MONITORING HOLLOW STEM DIA.OF BOREHOLE 8" D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS Sch. 40 TYPE OF CASING: 0 STEEL I PVC a OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS I HOSE j <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: I Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> + a SOIL BORING - a HAND AUGER GROUT SPECIFICATIONS Neat cement <br /> Q OTHER:. a OTHER APPROX.BORING DEPTH -45-59 .0 BOLTED TRAFFIC BOX or 8 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED None (if YES,list specifications in comment section) <br /> i COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT,PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> I <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed P p(tJt - Title/Company' Pro feet Manager <br /> Print Name Paul Anderson Date lI 2l Ztd 1 <br /> r DEPARTMENT USE ONLY * i <br /> SITE MAP IN UNIT W FILE,ADDRESS: 1.7 S; JJ <br /> WORK PLAN DATED: <br /> Application'Accepted By Date Issued ��5-0 Area D� <br /> Grout Inspection By Date - Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> I <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 601 g `L -2-131 SR � Z <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD29-02-001 WEB - - <br /> 9/11/20071 y <br />