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- 3 _ <br /> San Joaquin County Flt COPY <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.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 andlor 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 /> Port Road 21 •L ' Assessors ,I far <br /> WELL Location Cross Street Port Road M City Stockton Zip 95201 Parcel# I`f��3Q� f <br /> PROPERTY ji , <br /> Owner Port of Stockton t Address2201 W. Washington St City Stockton Zip 95201 Phone# (209) 946-0246 <br /> C-57 Contractor RSI Address220 N East Street City woodland Zip Lic# 802334Phone# (530) 668-2424 <br /> Consultant/SubCntrWGR, Southwest, Inc•.Address�l5 W Pine st ste eCity Lodi Lic# Phone#209.334.5363 <br /> GIS Coordinates:X 'Y Township Range ` Section <br /> WORK TO BE PERFORMED: <br /> [;NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) a DESTRUCTION (choose type below) <br /> aCSOIL BORING# 5 a OVER-BORE. DIAMETER <br /> a WELL# ( a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> Y <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE 2" a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:NA <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS Nas TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEALapprox. 13' TREMIE TYPE TO BE USED: GAUGERS 5HOSE <br /> a AIR SPARGE/OZONE UPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 8 Yes a No (107E: MAXIMUM FS EE-FA/l DEP7H IS 30') <br /> WSOIL BORING a HAND AUGER GROUT SPECIFICATIONS Portland Cement <br /> a OTHER: a OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NA (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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed xf � � Title/Company Project Manager/WGR Southwest, Inc. <br /> Print Name Steve Brumm Date March 16, 2007 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: pA I�u ;q, t-ry� <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued 3 U Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <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 /> �o 5-16�7 1E 3jLA SR# SDlb� <br /> C-57— WC -WAIVER_ C-57 Letter of Authorization to sign permit_EncroachFnent doc ++r W <br /> EHD 29-02-001 <br /> 6122104 <br />