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'man Joaquin County <br /> 000V <br /> Environmental Health Department ���E E <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 TION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd JA/V 15200VNIT IV <br /> Well Permit Application ENVIRONMENT NEA <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMlT/SE lTH <br /> Application is hereby made to San Joaquin County for a permit to construct <br /> of San and/or install <br /> County described, <br /> This Health application <br /> i eF�n� ompliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the StandardsAssessors <br /> Corner W <br /> of charter ay NA <br /> WELL LocatlonEast Bide of stanislaus st. a north. side Cross Street s stanislaus sc City Stockton Zip 95206 Parcel# <br /> of E.Charter way,city of stockton R-O-W, across from 701 E.Charter way <br /> PROPERTY22 E. Weber Avenue Cit STOCKTON Zip 95202 Phone#_(209) 937-8411 <br /> Owner City of Stockton Address y <br /> C-57 Contractor_,, D 9 Address 950 HoWP Ave. City Mar nez Zip 94553Lic# 656407 Phone# (92S)313-5800 <br /> Consultant/Sub Cntr Advanced ceoFnvironmen.///,tarfl Address A Sha R9 <br /> City Stockton Lic# eRng27 Phone# (9091467-1006 <br /> -1 Q <br /> GIS Coordinates:X <br /> 3T. ( � Y-If/ • Township Range Section <br /> WORK TO BE PERFORMED: <br /> 6 NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) a DESTRUCTION <br /> ORE. DI (choose type below) <br /> 0 SOIL BORING# <br /> B WELL# Mw_S Mw_F MW-i i 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 8 MONITORING B HOLLOW STEM DIA.OF BOREHOLE-8.2 5"a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCHD 40 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 241 TREMIE TYPE TO BE USED: B AUGERS a HOSE <br /> p AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ftYes 0 No (NOTE: MAXIMUM FREE-FA/I DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Tv__na IT Portland <br /> 0 OTHER:_D OTHER APPROX.BORING DEPTH 48' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS Installation of around water monitoring wells MW-5 MW-6 & MW-11 in the City of Stockton R-O-W <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 Ordinan es tjles and Regulations) and all applicable California State Laws. <br /> C � / <br /> Signed x Title/Company Project Scientist <br /> Print NameAll v rnl av;ra Date 01/15/09 <br /> DEPARTMENT USE ONLY <br /> �o P ivrnl`- <br /> SITE MAP IN UNIT IV FILE, ADDRESS: D_ l�/ �. � <br /> WORK PLAN DATED: / <br /> Application Accepted By v Mt/i�/s��l Date Issued - R Area <br /> Grout Inspection By Date/ r L3 D� Final Inspection By m Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 5 EC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3�, r 3!5 ' �'3Y3 SR#CfiSC. _35-I <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22,04 FILE COPY <br />