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•San Joaquin County *cmydILE COPY <br /> y c� Environmental Health Department SEP 1 9 2007 SITE <br /> 600 E. Main Street, Stockton,CA 95202-3029 MILIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.Sjgov.org/€W1R0NMEN THEAL KNIT IV <br /> ORN`P Well Permit Application PERMIT/SERVICES <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 Location Reid Drive Assesso <br /> Cross Street Luce Ave. City Stockton Zip Parcel# 16'uool <br /> PROPERTY Port of Stockton 2201 W.Washington St. Stockton 95201 (209)946-0246 <br /> Owner Address City Zip Phone# <br /> C57 Contractor RSI Drilling Address 220 N. East Street City Woodland Zip Lic# 802334,hone# (530)668-2424 <br /> Consultant/Sub Cntr WGR Southwest, Inc. Address 315 W. Pine St.Ste 8City Lodi Lic# Phone# (209)334-5363 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> D NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION (choose type below) <br /> X SOIL BORING#-8 DOVER-BORE. DIAMETER <br /> 0 WELL# D PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_2"_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:__ <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL D PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_6' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE X PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes X No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> X SOIL BORING D HAND AUGER GROUT SPECIFICATIONS_Bentonite pellets <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH 6'Max D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 Ord' ances, Rules and Regulations, and all applicable California State Laws. <br /> Signed xK1A�GC,r,I Title/Company Project Manager WGR Southwest <br /> Print Name Caryl f9hheehan Date 04 Sep 2007 <br /> DEPARTMENT USE ONLY /J /J <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /r PcL�_ �caKue eg A.,. zi e — /�S///I�Zt/LpltT�si( <br /> WORK PLAN DATED: -0 <br /> Application Accepted By Date IssuedUrl IR III MID—Area D(6 4 0� <br /> Grout Inspection By Date d Final Inspection By —'—'fSate �y 2i/ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> o 6B ft'9. ' !/oQ� C 7po sRI l�SZaz� <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc /V <br /> EHD 29-02-001web <br /> 6/12/04 <br />