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o San Joaquin County ORIGINAL <br /> 4 Environmental Health DepartmenA <br /> �,& SITE <br /> : 600 East Main Street, Stockton,CA 95202-3029 /� ve*rIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgo t�edV j 5 2 pO <br /> ft <br /> UNIT IV <br /> Well Permit Application �Rq� 9 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE tSSUi FAA��� <br /> Application is hereby made to San Joaquin County for a permit to construct aexYor Inst to work described. This V/ �Ss 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 /> WELL Location Cross <br /> Country Club Blvd <br /> Country Club Blvd. <br /> Cross Street& Mission RdCtty Stockton Zip 95204 p�aroeW 123-191-02 <br /> PROPERTY 1856 Country Club Blvd. <br /> Owner Phil Elder AddressC#y Stockton ZIp 95204 ��209-662 0952 <br /> C-57 Contactor Gregg Drilling gess 950 Howe Rd. CItyMartinez Zip94553 � 485165Phoneatt 925-313-5800 <br /> A.G.E. 837 Shaw Ptd. Stockton 209-467-1006 <br /> Cansulfant i Sub Cntr Address City Lka1 Phone# <br /> Cfi3 Coordinates:X�.,Y"'j '1t �Z- ,Township 2N Rarw 6E Section 33 <br /> WORK TO BE PERFORMEDo <br /> Q NEW WELL/BORING (Cpl,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') :8 DESTRUCTION (choose type below <br /> Q SOIL BORING S OVER-BORE DIAMETER 8' & 10 <br /> Q WELL 0 Q PRESSURE GROUT '\ <br /> Q•od GROUT SPECIFICATIONS <br /> COMMENTS: wells MW-1 through Mir-4 will be drilled-out with 8" augers; MW-5 will be drilled out with 10" augers <br /> TYPE <br /> NITORING LLOW STEM DIA.OF r rr <br /> Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA- '� � <br /> Q EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL XFPVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 21o' TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE:MAXIMUM FR E-F LL DEPTH 13 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS gn <br /> Q OTHER: A OTHER APPROX.BORING DEPTH 2-& Q BOLTED TRAFFIC BOX or fl ROVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specification in cornment section) <br /> COMMENTS, See RWQCB letter, dated 12 June 2009 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORVJNG HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby cer ft 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 /> • • �_ -- <br /> Signed x ,[a Tiite/Comparty PROJBCT MANAGER/A G..E <br /> OF <br /> Print TIMOTHY J. CUELLAR Date 06/15/009 <br /> DEPARTMENT U IIS:ONLY <br /> .a/c <br /> SITE MAP IN UNIT IV FILE,AD RESS: <br /> WO�LAR.DATED• <br /> Application Acoepted By Date I _Area 0Ob <br /> Grout kispeattw By Date Final inspection &A D Zoe i <br /> Destruction inspection By Date f <br /> COMMENTS 1CONDnxm: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK E RECD BY DATE PERMIT/SERVICE REQUEST* INVOICE <br /> 4 3s Got 3/5 -!s•o SR# <br /> C-57-_ WC -WAIVER_ C-5 etter of Authorization to sign permit--v/--Encroachment doc--V <br /> EHD 29.02.001 WEB <br /> 9111/2007 <br />