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San Joaquin County —COPY <br /> Environmental Health Department SITE <br /> y: 30.4 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 /> P <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 /> Assessors �/ <br /> WELL Location Port Road 21 + Port Road M Stockton 95201 LI 5 0340 <br /> _Cross Street City Zip Parcel# � ! <br /> PROPERTY <br /> Owner Port of Stockton Address2201 W. Washington StcityStockton Zip 95201 Phone# (209) 946-0246 <br /> C-57 Contractor RSI AddreSS 220 N East Street City Woodland Zip Lic# 802334Phone# (530) 668-2424 <br /> Consuftant/Sub CntrWGR, Southwest, Inc• Address315 W Pine st ate 8 City Lodi Lic# Phone#209.334.5363 <br /> GIS Coordinates:X 'Y_ Township Range Section <br /> WORK TO BE PERFORMED: <br /> vNEW WELL I BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> IFSOIL BORING# 5 a OVER-BORE. DIAMETER <br /> D WELL# a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA..OF BOREHOLE 2" a MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DIA:NA <br /> a EXTRACTION fl AIR HAMMER/DRIVEN CASING THICKNESS NA _._TYPE OF CASING: a STEEL a PVC p OTHER: <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEALapprox. 13' TREMIE TYPE TO BE USED: I]AUGERS IFHOSE <br /> U AIR SPARGE/OZONE BUSH POINT(GP or CPT)GROUT SEAL PUMPED: 8 Yes p No (1 07E: MAXIMUM F5 EE-FAI I DEP711 IS 30') <br /> W-SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Portland Cement <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or 0 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 Title/Company Project Manager/WGR Southwest, Inc. <br /> Print Name Steve Brumm Date March 16, 2007 <br /> DEPARTMENT USE ONLY a <br /> SITE MAP IN UNIT IV FILE, ADDRES : ! wr " ;q, <br /> -t� <br /> WORK PLAN DATED, �t �G <br /> Application Accepted By / [' Date Issued 310lb 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 /> SRS sdla � <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment clot +✓ <br /> EHD 29-02-001 <br /> 6/22/04 <br />