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r FJLE—W <br /> WELPPERMIT APPLICATION FORM SITE <br /> �q SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> I 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 /� <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED /�`" ` <br /> J {—^• CC)5 <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 /> WELLLocatlon1937 Longdon Drive cross Streepurney Fall FCItvStockton Zp 95206 acedsors <br /> PROPERTY Owner Ci ty of Stockton Address City Zip Phone# <br /> C-57 Contractor Spectrum Explor. Address 2365 Wigwam Drive cltySt0cktonzp95205LIc#51226BPhone#209-465-8712 <br /> Consultant/Sub Cntr Geomatrix Consul . Address2444 Main Street city Fresno Phone# 559-264-2555 <br /> Preliminary 37.932N 121.312W 1N 6E <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) U DESTRUCTION (choose type below) <br /> SOIL BORING t D OVER-BORE. DIAMETER <br /> WELL# MW L D PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS See diagram attached <br /> Ig MONITORING (XHOLLOW STEM DIA.OF BOREHOLE_ D MULTIPLE CASINGS 0MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS D HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER: n OTHER APPROX.BORING DEPTH XI 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 Ordinancyfs, Rules a d Regions, all applicable California State Laws. <br /> Signed x /� `. Title/Company Principal Scientist <br /> Print Name Timothy G. SoUther Date 5/28/03 <br /> DEPARTMENT USE <br /> ONLY /�y��D,.I <br /> SITE MAP IN UNIT IV FILE, ADDRESS: G o� L(1 c ( C -wac'c <br /> WORK PLAN DATED: <br /> Application Accepted By Date Iss O 1 TED 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 DATE PERMIT/SERVICE REQUESTI! INVOICE <br /> Zq0 1011 5-!0-6SR <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br /> , le- <br />