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t <br /> Pq�' N an Joaquin County <br /> o -. . e <br /> " rD F. _ <br /> � 1-, << / fir ental Health Department SITE <br /> ' 0 E�� (�Veber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> A (I� O ) 68-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br /> UNIT IV <br /> oq< rr` oaN`P ENVIKulYlviLIVI HL r <br /> \ -- PERMIT/ RVlc; e� 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, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors q <br /> WELL LocationFront of 736 N Hunter Cross Street Flora City Stockton Zip 95206 Parcel# NA GoS <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-57Contraclor Cascade Drilling Address 3632 Omec Circle City Zip Lic# Phone# <br /> Consultant / Sub Cntr Advanced ceoEnvironmental Address 837 Shaw Rd City Stockton Lic# 6ae227 Phone# ( 209 ) 467 - 1006 <br /> GIS Coordinates: X , Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> 8 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH , HAND-AUGER, OTHER`) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING # 0 OVER-BORE. DIAMETER <br /> 0 WELL # MW - 15 0 PRESSURE GROUT <br /> 0 `Other GROUT SPECIFICATIONS <br /> COMMENTS : <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING 8 HOLLOW STEM DIA. OF BOREHOLE 8 ° 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 0 . 145 TYPE OF CASING: 0 STEEL D PVC 0 OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 45 TREMIE TYPE TO BE USED: RAUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: flYes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Cement <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 60 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED RO (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 s, Rules and Regulations, and all applicable California State Laws, <br /> Signed Title/Company AGE /Staff Geologist <br /> Print Name Daniel Villanueva Date 08 / 11 / 2010 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : 71S ALI, ,Jarn.t4a. Sf• f . �L;1 - Codes <br /> WORK PLAN DATED : YYI bALe,-- ( U, 2,V 10 O <br /> Application Accepted By - Date Issued ! [ OD Are / <br /> Grout Inspection BY-A Date tjj A110 Final Inspection By Lf/- ,_+ � '"t�t Date % I <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS:. UCL 52 /p0800 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> jS . DI I ZZ - 12 Z ' 31 L(o l 8 r o SR# �0 6o <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EHD 29-02-001 h <br /> 6/22/04 IO �V / ;i— e-L.4'J % -3s- . 2v(40 <br /> W03 <br />