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`5an Joaquin County o <br /> ?, Environmental Health Departmen�� �,S� <br /> `< 600 East Main Street, Stockton, CA 95202-3029 FILEc��k4TIGATION <br /> SITE <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgo������ ?0 <br /> Well Permit Application <br /> �1R`n'�, 09 UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES�I�YEAR FROM DATE ISSUED 1 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applic,Tibn7ls made in compliance with Sar <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 1856 Country Club Blvd. Country Club Blvd, <br /> WELL Location Cross Street& Mission Rd Stockton Assessors <br /> City Zip 95204 parcel# 123-191-02 <br /> PROPERTY Phil Elder 1856 Country Club Blvd. <br /> Owner Address City StocktonZip 95204 phone# 209-662-0952 <br /> C-57 Contractor Gregg Drilling 950 Howe Rd. City Martinez Zi94553 Li485165 925-313-5800 <br /> p <br /> c# phone# <br /> Consultant/Sub Cntr A.G.E. 837 Shaw Rd.Address City StocktonLic# Phone# 209-467-1006 <br /> "" <br /> GIS Coordinates:X ���p 2N <br /> Y^ 2- , Z-z_ ,Township Range 6E Section 33 <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) ]a DESTRUCTION (choose type below) <br /> 0 SOIL BORING# <br /> 0 WELL# JJOVER-BORE. DIAMETER 8" & 10" <br /> 0*Other 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS O� <br /> COMMENTS: Wells MW-1 through MW-4 will be drilled-out with 8" augers; MW-5 will be drilled out with 10" augers <br /> PE OF WELL IN ALLATION TYPE CONSTRUCTION SPEC_I [CATIONS <br /> MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:Z t <br /> 4 <br /> NITORING HOLLOW STEM DIA.OF BOREHOLE It <br /> 0 %A <br /> 0 EXTRACTION �OAIR HAMMER/DRIVEN CASING THICKNESS_ TYPE OF CASING: 0 STEELPVC 0 OTHER: V110 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 210 TREMIE TYPE TO BE U ED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FR E-F LL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_G OTHER APPROX.BORING DEPTH_ 0 BOLTED TRAFFIC BOX or 0 OOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS. See RWQCB letter, dated 12 June 2009 <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x '(/• y-6— Title/Company PROJECT MANAGER/A.G.E. <br /> Print Name TIMOTHY J. CUELLAR Date 06/15/009 <br /> DEPARTMF,NT USE ONLY �^ AIC_ <br /> SITE MAP IN UNIT IV FILE,;/PpRESS: a5 Sb 35.Z(c <br /> WORK PLAN DATED: /� <br /> Application Accepted By Date Issued �'d� Area <br /> Grout Inspection By Date Final Inspection By Date 7— 1 O <br /> Destruction Inspection By Date '7-1—6 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 4W 3� <br /> 35. 60f 5 2� -15.6 sR# as755 <br /> C-57_ WC_-WAIVER_ C-57/Letter of Authorization to sign permit_Encroachment doc�N'X <br /> EHD 29-02-001 WEB <br /> 9/11/2007 FILE COPY <br />