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C(DPY <br /> ''' . �b San Joaquin County <br /> 4. ?� 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 <br /> 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 /> Port Road 21 + Assessors <br /> WELL Location '} Cross Street port Road M City Stockton Zip 95201 Parcel# L4d <br /> PROPERTY <br /> Owner Port of Stockton Address2201 W. Washington St City Stockton Zip 95201 Phone# (209) 946-0246 <br /> C-57 Contractor RSI Address220 N East Street ' City_ oodland Zip Lie# 802334Phone# (530) 668-2424 <br /> Consultant/Sub CntrWGR, Southwest, Inc•AddresS315 W Pine st ste 8 City Lodi Lic# Phone#209.334.5363 <br /> i <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> BKNEW WELL!BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> [FSOIL BORING# 5 a OVER-BORE. DIAMETER <br /> 0 WELL# a PRESSURE GROUT <br /> p'Other GROUT SPECIFICATIONS <br /> COMMENTS: — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:NA <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL O PVC BOTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALapprox. 13' TREMIE TYPE TO BE USED.' B AUGERS ff HOSE <br /> p AIR SPARGE!OZONE BUSH POINT(GP or CPT)GROUT SEAL PUMPED: N Yes D No (107E: MAXIMUM F5 EE-FA/l DEPTH IS 30') <br /> SOIL BORING p HAND AUGER GROUT SPECIFICATIONS Portland Cement <br /> Q 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 preparedthis 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 /> Signedx " �"''� Title/Company Project Manager/WGR Southwest, Inc. <br /> Print Name Steve Brumm Date March 16, 2007 <br /> pDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRES : <br /> WORK PLAN DATED.:�v��l <br /> Application Accepted By 1 i' Date Issued 31 /� :2 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> H. <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> I SR# <br /> C-57^ WC -WAIVER—.— C-57 Letter of Authorization to sign permit_Encroachment doc r✓ <br /> EHD 29-02-001 <br /> 5/22/04 <br />