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�I <br /> �oR0.U ! y. , ,�o fin Joaquin County <br /> I Q Environmental Health Department SITE <br /> i 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> oRN�P 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 County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 1901 S . E1 Dorado Street Fifth Street Stockton 95206 Assessors 16508019 <br /> WELL Location Cross Street City ip Parcel# <br /> PROPERTY 1901 SE1 Dorado St <br /> Owner Mohammad MS . orao Plater Address City Stockton Zip 95206 Phone# <br /> C-57 Contractor Greggpp /y Drilling Address 950oHowec�Road,) fOilyMartinez Zip9455/3 Lid! 656407 ( 925 )( 925 ) 313 - 5800 <br /> Consultant / Sub Cntr/ryAned 6 CFAV�ILW Address o37 ,54aujh act City . 444 Lic# p 'W02.77 Phone# <br /> GIs Coordinates: X , Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> x4rcNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> )WSOILBORING # CPT - 1 through CPT- 3 aOVER-BORE. DIAMETER <br /> a WELL # a PRESSURE GROUT <br /> a *Other GROUT SPECIFICATIONS <br /> COMMENTS: Three on- site CPT8 to total depth of 1201 , <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA. OF BOREHOLE 2 11 a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> n EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: g STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 1201 TREMIE TYPE TO BE USED: 'AUGERS a HOSE <br /> 0 AIR SPARGE/ OZONE )a PUSH POINT (GP or CPT) GROUT SEAL PUMPED: g Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 1 SOIL BORING O HAND AUGER GROUT SPECIFICATIONS Type II Portland Cement <br /> p OTHER:.a OTHER APPROX. BORING DEPTH 120 0 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 Or finances, /u ss .and <br /> .Regulations, and all applicable California State Laws. <br /> Title/Company Yl 7c Selerorzr S7l <br /> Print Namemal <br /> _ a [(p - �Gli�vi,Wr'z'�- Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : I q o ( t r- t I> o nL s (� 5 yr w�z� <br /> WORK PLAN DATED : vu <br /> Application Accepted By '� • Date Issued I O� Area <br /> Grout Inspection By Date Final Inspection By Date O1. 7,wt > <br /> Destruction Inspection By Dale <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> 5sr a 84• TiS3, o� Z6 ats'i <br /> m t 4 \ � r. (,o3 SR# c s. 32'}z. <br /> ✓J <br /> C-57.-�/ WC./-WAIVER. C-57 Letter of Authorization to sign permitjelEncroachment doc <br /> EHD 29-02-001 WEB <br /> 9/11 /2007 <br />