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C; P4 ' " San Joaquin County <br /> o <br /> Q Enviro, _cental Health Department SITE <br /> " { 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 /> 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, Cha. ptet 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 5 . ae -pe ^bo s Assessors <br /> o <br /> WELL Location City f Stockton Right of Waycross Street Fifth street City Stockton Zip 95206 Parcel# ,;IJUPc <br /> PROPERT� it of Stockton 345 N . El Dorado St . ( 209 ) 937 - 8266 <br /> Owner y Address City Stockton Zip 95206 Phone# <br /> C-57 Contractor Gregg Drilling Address Howe Road City Martinez Zip 94553 Lic# 656407 Phone# ( 925 ) 313 - 5800 <br /> Consultant / Sub Cntr 4d va ^ceal l'<o Lnvkl ;lM�A'ddress 331 Skan) rd City S42i440fiM Lic# .&SdQZj- Phone# .2O�j li ' - G!'q/p <br /> GIS Coordinates: X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ISI x4yNEW WELL / BORING (FpCAEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) p DESTRUCTION (choose type below) <br /> XU SOIL BORING # 0 OVER-BORE. DIAMETER <br /> 0 WELL # 0 PRESSURE GROUT <br /> a *Other GROUT SPECIFICATIONS <br /> COMMENTS ; One off - site CPT to total depth of 1201 <br /> . <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE22� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> U EXTRACTION n AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL U PVC 0 OTHER: <br /> U VAPOR U MUD ROTARY DEPTH OF GROUT SEAL 120 TREMIE TYPE TO BE USED: IVAUGERS <br /> 0 HOSE <br /> 0 AIR SPARGE/ OZONE {I PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ;a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Type II Portland Cement <br /> 0 OTHER:.0 OTHER APPROX. BORING DEPTH 1201 0 BOLTED TRAFFIC BOX or p 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 /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordir� nces, R �s/land Regulations, and all applicable California State Laws. fie ' <br /> Title/Company SfaCrf�X4� OK4111- <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : L R. o t S- E ( 1)o r evly 5 C- <br /> WORK PLAN DATED :: II D (�t l � �— <br /> Application Accepted By 6'1 x '1- Date Issuedu Area 1 <br /> Grout Inspection By Date Final Inspection I Date 4 <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 REQUEST # INVOICE <br /> 3 T� 91 00 <br /> so3 2a4vo 3s3 . 0 � z6Rs� 2� r � o3 SR#OOS32�3 <br /> C-57, WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD29-02-001 WEB <br /> 9/11 /2007 <br />