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i <br /> in Joaquin County <br /> 1 Environmental 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 /> FILL <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 /> p Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 81 Dorado St . & Assessors <br /> WELL Location <br /> 3147 S . El Dorado street Cross Street �"}" soe . city Stockton Zip 95206 parcel# / 75 / 2 Or73 <br /> PROPERTY 3105 S . E1 Dorado St . Stockton 95206 2.09 - 466 - 3554 <br /> Owner Cal Tank Lines Inc . Address City Zip Phone# <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez Zip 94533 Lic# 65 - Phone# ( 925 ) 313 - 5800 <br /> Consultant / Sub CntrVdROeaceoanv emit Address 837 Shaw Road City Stockton Lic# Phone# ( 800 ) 511 - 9300 <br /> GIS Coordinates: X., y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,&NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,. OTHER`) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING # a OVER-BORE. DIAMETER <br /> EXNELL # VW- 1 , VW- 2 &VW- 3 a PRESSURE GROUT <br /> a *Other GROUT SPECIFICATIONS <br /> COMMENTS: See Work Plan dated 01 July2008 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING }f41OLLOW STEM DIA. OF BOREHOLE 10 „ a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ 4 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS sch . 40 TYPE OF CASING: 0 STEEL AkPVC 0 OTHER: <br /> ificVAPOR a MUD ROTARY DEPTH OF GROUT SEAL 5 ' - 6 ' TREMIE TYPE TO BE USED. VAUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes 137No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Type II <br /> a OTHER: h OTHER APPROX. BORING DEPTH 30 ' AyBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED No (if YES , list specifications in comment section) <br /> COMMENTS: See EHD - approval letter dated 25 July 2008 <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 Ordinances, Rules and Regulations, and all applicable California State Laws/. <br /> Signedx x` 171,%!�t/1. f1' r1/V� Title/Company ��f�i Vim. lei t_ f Ll • �1(/ tJ ° t> 'l L�t.✓U tui %qq fit <br /> u <br /> Print Name _i.-. G� 1-�' i '1 '1 �t �f lu �"I � Date <br /> DEPAR-ITMENT 115E-OMI V <br /> SITE MAP IN UNIT IV FILE, ADDRESS : 3 14 7 S o v +k EL I) e1 r d dy S+Fre e <br /> WORK PLAN DATED` :/ 2009 <br /> Application Accepted By V I GFo r L C (1 Y-i"} Bis Date Issued h / 10) 15' - O �Ai � Area�S�- <br /> Grout Inspection By �I [.'1'er ,` Ce M@•G/I hfr✓�Date 11- 17 • L 8 Final Inspection By Y i it N 1 a #%&L6`F`r71. 4t+ Date LI ` I� - 0 <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: S + S O y a IQ nr H VW - I -2 and - <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # RECO BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 3501 2832 %Z /e -/5-08 SR# 00SS1� 84 <br /> O0 � <br /> 3503 315- bo 404 . 00 <br /> C-57_ WC.-WAIVER. C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD29-02-001 WEB <br /> 014 419n <br />