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i <br /> ut <br /> San Joaquin County <br /> Environmental Health Department � , SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 2007 MITIGATION <br /> P' (209)468-3449 Fax: (209)468-3433 Web: www.SjgoV-. �EWUE/VTtiE UNIT IV <br /> x0 Well Permit Application x'91/1SfiRVIC <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FILE CUPY <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 /> WELL Location Landscaped area,City of Stockton R-o-W cnCross Street Monroe Ave.City it Stockton Zip 95,204 Parcel# NA <br /> North side of Harding Way across from 244 W.Harding way <br /> PROPERTY !�' <br /> Owner Cit of Stockton Address 22 E. Weber Avenue City STOCKTON Zip 95202 Phone# (209) 937-8411 <br /> C-57 Contractor Gregg Drilling Address CityMartine75Zip 94553LiC# 656407 Phone# 1925)313-5800 <br /> - <br /> Consultant/Sub Cntr Advanced GeoEnvironmentaLAddre55 R17 .4haw Rr3 city Stockton LIC# 680227Phone# <br /> GIS Coordinates:X Y Township i Range Section <br /> WORK TO BE PERFORMED: I� <br /> B NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> RSOILBORING# H-7,H-S DOVER-BORE. DIAMETER <br /> a WELL# j 0 PRESSURE GROUT <br /> C*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS it <br /> 0 MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE_=_ a MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> 0 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 SEALsFr-Tn ' TREMIE TYPE TO BE USED: 0 AUGERS p HOSE <br /> 0 AIR SPARGE/OZONE It PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FA/I DEPTH IS 30') <br /> O<SOILBORING aHAND AUGER GROUT SPECIFICATIONSTie TI Portland __- <br /> 0 OTHER: a OTHER APPROX.BORING DEPTH 25' !! (]BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Ij (if YES,list specifications in comment section) <br /> COMMENTS: <br /> ij <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4U WORKING HOURS NOTICE REQUIRED-0011 INSPECTIONS. <br /> 3 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> I, County Ordinances Rules an R�,Iatlons l and all applicable California Stated Laws. <br /> Signed x Title/Company <br /> Print Name Ai;cnn rni av;ra Date 6 rg in7. <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ---)6o Brock of 14a d J n o d✓G u <br /> 7 <br /> WORK PLAN DATED: JL1n tJa _73 _ zoa � <br /> Application Accepted`By V G"f o r L • r+ Date Issued b Area24-5- <br /> Grout Inspection By V%� j+riiiti I-. rnF�QYfiz4+� Date ? Final Inspection By Date 16, 12-0 107 <br /> Destruction Inspection By Date i� I <br /> COMMENTS 1 CONDITIONS: 1r 63'i' <br /> ACCOUNTING ONLY: AlD# FAC# :! <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 5EC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3501s9.ao 374. OP 2574 / i` sR# 00 S08 G4 <br /> EZ)3 .�$ .as <br /> C-57 WCT WAIVER_ C-57 fetter of Authorization to sign permit Encroachment doc__._ <br /> EHD 29-02-001 <br /> 6122/04 <br />