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.'�x C CEL-WED • SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> .. SEP © 32008 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Tele h :(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> 0NVIR0NMENT HEPAI�i� UNIT IV <br /> PERMIT/SERVICES WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Count gevP opLpent liitl gger tt1115i3 Bnd the Stan4acskof Sfn Jo�c�uenCounty Environmental Health Department. <br /> etwee p9u �bree nus ria rive an c in ey <br /> Well Location 9 > G• �5 Stockton Assessor's r1 9% <br /> 3 Cross Street City Zip 95206 Parcel# ! ' 'F 7 <br /> Property Union Pacific Railroad 9451 Atkinson Street Roseville <br /> Owner Address Cit), Zip 95747 phone# 916.789.5184 <br /> C-57 Contractor iiiictpNkI I* Address•52ji ABlvd. city � LiD# 7o"f�`�PnDne 98S•52/•l`�90 <br /> ARCADIS U.S.,In 950 Glerui Drive, IF <br /> 125 Folsom 916.985.2079 <br /> ConsultanVSub Cntr Xddress City LID# Phone <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW YELLIBORING(CPT,GEOPROSE,H DROPUNCH,HANqAUGER,OTHER`) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> Ila SOIL BORING# (�P– IO �a L, (.; "a� -1 OVER DIAMETER <br /> ❑WELL# �� <br /> ❑`OTHER ❑PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> 0 EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING:0 STEEL 0 PVC 0 OTHER <br /> 0 VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE IVPUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:Cl Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> EsrS01L BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER: APPROX.BORING DEPTH I C/ El BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING PROPOSED (If YES,list spedreallons in o rn,nent section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that 1 have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signedr�L/i12iO�& O"e, --y.� Title/Company Associate Project Manager/ARCADIS U.S. ,Inc. <br /> Print Name Danielle Catlin-Wright <br /> Date_ Off• aS 0� <br /> q <br /> DEPARTMENT USE ONLY <br /> SITE <br /> L <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 83 I,• 7 dlGt t 7"00 "lA� <br /> WORK PLAN DATED: b -Z a cle Q <br /> APPLICATION ACCEPTED BY DATE ISSUED / d AREA_71 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE 6 ZS 8 <br /> DESTRUCTION INSPECTION BY � � � 1� DATE <br /> COMMENTS/CONDITIONS: aA&A Ifn3 .tn-.-tac..a.y sU e';✓ f <br /> ACCOUNTING ONLY: AID# FAC# <br /> 2PECOO�E�SFFE;E INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 1 5 ' 7777 111/10 r I SR#0St31 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN FtHMIT ENCROACHMENT DOC <br /> EHD 29-01 17/5/07(WEBJ <br /> WELL PERMIT APP <br />