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oPq I fan Joaquin County <br /> , o <br /> Enviro_ -.rental Health Department <br /> " :K 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web : www.sjgov.org/ehd ) 7IT IV <br /> Well Permit Application Ff - - _ <br /> r re �iC.FtLI % , <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 /> City of Stockton Right of Way S . El Dorado/Fifth St Stockton 95206 Assessors <br /> WELL Location Cross Street City Zip Parcel# <br /> PROPERTY <br /> Owner City of Stockton Address 345 N . El Dorado St CityIIII Stockton Zip 95206 Phone# <br /> C-57 Contractor Adv G,,4yeooenvironmenta1 Address 837 Shaw Road City Stockton Zip 95215 LiC C57 - 68022V hone# ( 209 ) 467 - 1006 <br /> Consultant / Sub Cntr4r'�f Vt &d 6-ee l7ilijet J Address D SIt J %C'elo / City-k/ 4 0AJ Lim L Y0227 Phone# <br /> GIs Coordinates: X , Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> x)ffNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER`) 0 DESTRUCTION (choose type below) <br /> x6SOIL BORING # 13 - 5 thru B - 8 0 OVER-BORE, DIAMETER <br /> 0 WELL # 0 PRESSURE GROUT <br /> n *Other GROUT SPECIFICATIONS <br /> Four off - s <br /> COMMENTS: rings trte soil boo depth of approximately 401 . 3 borings along E1 Dorado ; 1 on Fifth S' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE1-511 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL n PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 401 TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> n AIR SPARGE/ OZONE )a PUSH POINT (GP or CPT) GROUT SEAL PUMPED: Dyes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 305) <br /> :0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Type II Portland Cement <br /> 0 OTHER:.0 OTHER APPROX. BORING DEPTH 401 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 Ordi ances, Rule nd Regulations, and all applicable California State Laws, <br /> Title/CompanJafPAh5 II' <br /> Print Name C / °/C tt �:E1.Yl�t{.v Zit- Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : ( q o f 4 Cl 00t- a, L � <br /> WORK PLAN DATED : 7�cv <br /> Application Accepted By Date Issued Z }� Area tIr <br /> Grout Inspection By Date Final Inspection By mk Date1 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> SYS sN . &0 <br /> sdS111M A . M0383- '� J Z6tsS' -t` LIo'R SR#0052� 4 <br /> C-57 ✓ WCj,/'WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11 /2007 <br />