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Pgtliry San Joaquin County <br /> O. .CAm <br /> ' Environmental Health Department SITE <br /> � x-3¢4 fast Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> f 4 8-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> c•. <br /> -T-- CP � G 12 ajo Well Permit Application <br /> ENVr11U(v +Vv ( HEAE"EFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application i �l� �¢ t��J¢a�p�uuiiffn County for a permit to construct and/or install the work described . This application is made in compliance with San <br /> Joaquin County EMT men-( i I pter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location Front of 222 Flora Street Cross Street Hunter City Stockton Zip 95206 Parcel# NA e.0 ,5 <br /> PROPERTY <br /> Owner City of Stockton Address 425 N El Dorado City Stockton Zip 95202 Phone# 209 - 937 - 8212 <br /> Rancho Cardova 95742 938110 1 - 916 - 638 - 1169 <br /> C-57Contractor Cascade Drilling Address 3632 Omec Circle City Zip Uc# Phone# <br /> Consultant / Sub Cntr Advanced GeoEnyirQ=Qntal Address 837 Shaw Rd City Stockton Lic# 680227 Phone# ( 209 ) 467 - 1006 <br /> GIS Coordinates: X , Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> ® NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH , HAND-AUGER, OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING # a OVER-BORE. DIAMETER <br /> ® WELL # MW - 14 a PRESSURE GROUT <br /> a *Other GROUT SPECIFICATIONS <br /> COMMENTS : <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> EFMONITORING 8 HOLLOW STEM DIA. OF BOREHOLE 8 u MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 0 . 145 TYPE OF CASING: U STEEL g PVC 0 OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 45 TREMIE TYPE TO BE USED: RAUGERS p HOSE <br /> g AIR SPARGE/ OZONE a PUSH POINT (GP or CPT) GROUT SEAL PUMPED: fl Yes fl No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> g SOIL BORING u HAND AUGER GROUT SPECIFICATIONS Portland Cement <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH 60 a BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED no (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 OrR as, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company AGE / Staff Geologist <br /> Print Name Daniel Villanueva Data 08 / 11 / 2010 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : / S AJ• 22,9 <br /> WORK PLAN DATEDIl :// `Y4 <br /> Application Accepted B Issued 0 /.3 0010 Are <br /> Groin Inspection BDate C2 l i QFinal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: L • <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> SR# 60pol <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EHD 29-02-001 <br /> 6/22104 Z2 / Z 9 <br />