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o *San Joaquin County RREEIVE® <br /> Environmental Health Department JUN pg 2012 SITE <br /> " 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sj9GNVtR"ENTALHEALTH UNIT IV <br /> P <br /> Well Permit Application PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 <br /> 324 North Hunter Street <br /> WELL Location Cross Street Miner City Stockton Zip CA Parcel# 139-140-17 <br /> PROPERTY <br /> Owner Enterprise Rent-A-Car Address 199 North Sunrise Av(tily Roseville Zip 95661Phone# 916-787-4500 office <br /> C-57 Contractor Advanced GeoEnvironmentalAddress 837 Shaw Rd. City,Stockton Zip 95215Lic#680227 Phone#209-467-1006 <br /> Consultant/Sub Cntr same as above Address CityLic# Phone# <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> g NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) U DESTRUCTION (choose type below) <br /> IFSOIL BORING# off-site soil borings g OVER-BORE. DIAMETER <br /> p WELL# 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLEl 1/4 b MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL u PVC 0 OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS g HOSE <br /> a AIR SPARGE)OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: G Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> grSOIL BORING 0HAND AUGER GROUT SPECIFICATIONS Portland Type T/TT <br /> a OTHER: DdOTHER Geoprobe APPROX.BORING DEPTH 40' a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Boring will be located: ff the site the idealk a. he.. in approved w rkplan <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 Or�dlipna c s, Rules/an�rl3}�IJ�' gulations, and all applicable California State Laws. <br /> Signed O`C=G'`rApgu._ Title/Company r i agi�t r-Pac,,. ,PntnI r„, <br /> Print Name William Little Date 01 - 06- 2012 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: I�j 7� INl rn /tn i <br /> WORK PLAN DATED: rT I z& I I/ <br /> Application Accepted By CA1 Date Issued— II ll�' )-2 —Area- <br /> Grout <br /> reaGrout Inspection By � �aH Date t 7-0 (Z Final Inspection By�;. Pee Date t q 3o!/2 <br /> Destruction Inspection By Dale <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 /> 3SoS Its•oma 341-2 q G� trr;��2 SR# (oLl l 5 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc x <br /> EHD 29-02-001 <br /> 6/22/04 <br /> 3so3 ro '7>`fIZ`� <br />