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°gouty SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> " SITE <br /> I 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.Sigov.org/ehd UNIT IV <br /> 'f<iFOR� <br /> WELL 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 /> Assessor's <br /> Well Location 2947 Navy Drive Cross Street W. Washington St. City Stockton Zip 95206 parcel# 145-030-09/10 <br /> Property Port of Stockton <br /> Owner Address 2201 W.Washington St. City Stockton Zip 952o3-2942phone#209-946-0246 <br /> C-57 contractor Boart Longyear Address 3894 Railroad Ave. cityYuba City ty Zip 95991 Lic# 694686 Phone <br /> consultantsub cntr ARCADIS Address S1 t41�1tfl03Rocky Ridge Dr. City Roseville Lic# Phone 916-786-6554 <br /> GIS Coordinates:X 37.941644 ,Y 121.33L6t53 30 ,Township Range Section 3 i <br /> WORK TO BE PERFORMED: <br /> ®NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> [3 SOIL BORING# ❑OVER-BORE DIAMETER <br /> ®WELL# SP/M-96, $P M-9C ❑PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ®MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 7e 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2" <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS SCh 40 TYPE OF CASING:0 STEEL M PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 60 ft + TREMIE TYPE TO BE USED O AUGERS M HOSE <br /> 0 AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:M Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Neat Cement Grout <br /> ❑-'OTHER: MOTHER: Sonic APPROX.BORING DEPTH 70-90 ft M BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTM CASING PROPOSED (ff YES,rst speci8m8ans In moment seceon) <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed Title/Company Project Geologist-ARCADIS <br /> Print Name Jeremy Hughes <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: g�9 /�/-J <br /> WORK PLAN DATED: Z 0 <br /> APPLICATION ACCEPTED BY DATE ISSUED (01 10 AREA 4 <br /> GROUT INSPECTION BY a-K.Jn ka FINAL INSPECTION BY �C DATE �d/.." JD XIlp 0 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> OY07z7 n SR# 602,0 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PE IT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 <br /> WELL PERMIT APP <br /> PLie/.�� �(`J/D,�`]. 2 7 <br />