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ro <br /> Gan Joaquin County ED <br /> ` Environmental Health Department ECCE4W E <br /> w < LL {{ <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 TION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd JAN 15 2009 NIT IV <br /> FO Well Permit Application ENVjR 9 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMITEEj,�SE ENTH�//E+[,4nLTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application IsRin�th!41%ompllance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> corner of charter Way Assessors <br /> WELL Location"" .iae Of scamaaus sc. s north side Cross Streets stanaa.u. sc City Stockton Zip 95206 Parcel#NA <br /> ob 3.Charter Way,City of Stockton R-0 W, acro.. from loi s.Charter way <br /> PROPERTY <br /> Owner City of Stockton Address 22 E. Weber Avenue City STOCKTON Zip 95202 Phone# (209) 937-8411 <br /> C-57 Contractor arecig Drilling Address 950 Howe Ave. City -- Zip 94553Lic# 656407 PFI one# (925)313-5800 <br /> Consultant/Sub Cntr Advan a - ownyl rnnmental Address H57 Cham RA City Stockton Lic# 6Rn227 Phone# 12 0 91 4 67-1006 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> g NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> a WELL# mw-,, Mw-a MW-11 aPRESSURE GROUT <br /> g`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 11 MONITORING a HOLLOW STEM DIA.OF BOREHOLE 8_25"a MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA:?" <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS SCHD 4 0 TYPE OF CASING: Q STEEL 0 PVC a OTHER: <br /> g VAPOR g MUD ROTARY DEPTH OF GROUT SEAL 24' TREMIE TYPE TO BE USED: g AUGERS g HOSE <br /> g AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: .Yes a No (NOTE: MAXIMUM FREE-FA/I DEPTH IS 30') <br /> g SOIL BORING a HAND AUGER GROUT SPECIFICATIONS my=e TT Pnrrl and <br /> g OTHER: 0 OTHER APPROX.BORING DEPTH 48' $BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications In comment section) <br /> COMMENTS: Installation of ground water monitoring wells MW-5, MW-6 & MW-11 in the City of Stockton R-O-W. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4U 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 Orr�dinnan es Rt les and Regulations) and all applicable California State Laws. <br /> Signed W✓I Title/Company Project Scientist <br /> Print Name Ally-c, ­ .yjtn Dale 01/15/09 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> �Aj� <br /> Application Accepted BDate Issued /2r(/O� AJea 149 53 <br /> Grout Inspection By Dale Final Inspection By Date <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY, AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 5EC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3503 f S�G�/ z9sv3 SR# <br /> 93/SOoS6 3S� <br /> C-57_ W(--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />