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SAN JOAQUIN COUNTY <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sicov.orG/ehd UNIT IV <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 /> Well L.ocatim 2947 Navy Drive Cross Street W.Washington St. q Stock95206 Assess <br /> ots <br /> City ton Zip parcel# 145030-09/10 <br /> P<opainty Port of Stockton 2201 W.Washington St. 95203-2942 <br /> Owner Address BI City Stockton Tip Phone#209-946-0246 <br /> C-57 Contractor Boart Longyear Address 3894 Railroad Ave. City Yuba City TIp 95991 Uc# 694686 Phone <br /> ConsuHanUSUb Cntr ARCADIS Address 1410 U3 <br /> � Rocky Ridge Dr. qty Roseville Lie# Phone 916-786-655A <br /> GIS Coordlnmtas:X 37.941644 <br /> .y 121.3316tl!30 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> El NEW WELL/BORING(CPT.GEOPROBE,HVDROPUNCH,HAND-AUGER,OTHER-) El DESTRUCTION(CHOOSE TYPE BELOW) <br /> 0 SOIL BORING# ❑OVER-BORE DIAMETER <br /> ®WELL# SPIM-9B,SP/M-9C ❑PRESSURE GROUT <br /> [3'OTHER GROUT SPECIFICATIONS <br /> 0 EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [M MONITORING 0 HOLLOW STEM DIA OF BOREHOLE 7" 0 MULTIPLE EASINGS 0 MULTI-LEVEL WELL CASING DIA: 2" <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS SCh 40 TYPE OF CASING:0 STEEL ®PVC 0 OTHER <br /> C VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 60 h + TREMIE TYPE TO BE USED 0 AUGERS®HOSE <br /> C AIR SPARGEIOZONE D PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:M Yen 0 No (NOTE:MAXIMUM FREE.FALL DEPTH IS 30) <br /> 0 SOIL BORING C HAND AUGER GROUT SPECIBCATIONS Neat Cement Grout <br /> CloTHER: mI OTHER: Sonic APPROX.BORING DEPTH 70-90 ft W BOLTED TRAFFIC BOX OR 0STOVE PIPE <br /> CONIXIDTOR CASING%10POBED prYEa,An rQatllltaNgeh mn.rwX ngbl) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I rNreby11ut I.hava'p qd this application and that ttm work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Ragularuo all appllc M.CeI is Laws. <br /> Signed _TltierComperry Project Geologist-ARCADIS <br /> Print Name ererrry H ugiFes Date 0LO / Lj <br /> �DEPARTMENT <br /> USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: / ` �"I-t/^-L� ILK'`J �.�✓�-W(+ [-t� <br /> WORKPLAN DATED: <br /> APPLICATION ACCEPTED BY DATE SUED O AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE -�1916 t0 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMTREMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> �i0/ 8 Dyo7�� lJ <br /> 1611v 1 SR#602o2- <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERK41T ENCROACHMENT DOC <br /> EHD 29-01 10128109 WELL PERMIT APP <br />