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0,.41 R' "•..co SAN JOAQUIN COUNTY <br /> 2 4 ENVIRONMENTAL HEALTH DEPARTMENT/ 7 201ly SITE <br /> N. K <br /> 600 East Main Street, Stockton , CA 95200%02t � r MITIGATION <br /> c 4.. Telephone: (209) 468-3449 Fan: (209) 468-3433 Web s4rTov 6f�ITeFrd'�L�- f UNIT IV <br /> EIS <br /> WELL PERMIT APPLICATION HLE COPY <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 /> Ci}y o 'F Assessor's <br /> Well LdCation 3105 S . El Dorado St . cCffoss Street Ivy Avenue city Stockton Zip 95206 Parcel # <br /> Property 2 vnMjowel— <br /> Owner City of Stockton Address 345 N . Bl Dorado St . City Stockton Zip 9520 (1 Phone # Oq) 937 -$ 3$/ <br /> C-57 Contractor Tam Address 3911 W . Capitol Ave . City W . Sacramento LIC # 466270 Phone ( 516 ) 371 - 1690 <br /> Consultant/Sub Cntrr j,s Address 3911 w Capitol Ave . City W . Sacramento Lic # 466270 Phone ( 916 ) 371 - 1690 <br /> GIS Coordinates: X 37- VIS `IO 8401 UY - IZ 1 . 27406284379ownship Range Section <br /> WORK TO BE PERFORMED: <br /> ® NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUG R, OTHER*) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br /> ® SOIL BORING# Geo - IQ ❑ OVER-BORE DIAMETER <br /> ❑ WELL # i ' 10 El PRESSURE GROUT <br /> ❑ "OTHER I GROUT SPECIFICATIONS W <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ) I� <br /> ❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 211 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: lJ 1 <br /> ❑ EXTRACTION ❑ AIR HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br /> ❑ VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL SOI TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE (I „ <br /> ❑ AIR SPARGE/OZONE ® PUSH POINT (GP OR CPT),_G GROUT SEAL PUMPED: W Yes ❑ No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> IN SOIL BORING El HAND AUGER GROUT SPECIFICATIONS lot ea+ 6etstenf <br /> ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 501 ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE ' <br /> CONDUCTOR CASING PROPOSED (if YES, list specifcatims in mmment section) <br /> COMMENTS: <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS O <br /> I hereby certify that I 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. I <br /> rAi 601us <br /> Signed Title/Company Senior Geologist /Taber Q <br /> Print Name Thomas E - Ballard Date 9 - 28 - 10 <br /> DEPARTMENT USE ONLY 11 �P <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 3 1 O S s 1= I IlO Y' Ad O ST ree& <br /> WORK PLAN DATED: l u n e oZ 0 1 0 \rn� <br /> APPLICATION ACCEPTED BY V I G'-Fa r / el M c c0 r fn e .. DATE ISSUED / Q ' S3 - / O AREA <br /> GROUT INSPECTION BY Yie mdl: w.TNW" FINAL— I� BY DATE l�/ 1r/�'I°�77 �-J DATE /O IA 0 <br /> ' 111 ./0 <br /> DESTRUCTION INSPECTION BY DATE -Z r <br /> COMMENTS/CONDITIONS: Advort et'n. iyVV; 0"Tn o 1 1 O r7 nd s - r ak) ri <br /> ACCOUNTING ONLY: AID # FAC # <br /> PE CODES FEE INFO AMT REMITTED SNEeK # RECV'D BY DATE PERMIT/SERVICE # INVOICE <br /> 35- 0 , 2 . 00 y $ . o � MDt4R- � � <br /> 3x03 3G G . 00 la SR# 006 / 203 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD2MI 11/5107 (WEB) `� ��� �� � ^ ' V iIisgz RO-49 WELL PERMITAPP <br />