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LL kRMIT APPLICATION FO6' & SITE <br /> �( FL-71j;'�WED SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> F`k, n 4 '1005304 E. Weber, Third'Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> EWROIdVENT HEALTH FILL uurY <br /> pERM�T/SERVICES 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-Lodation 1030 South Olive Street Cross Street East Main City Stockton Zip Parcel# 157-264-22 <br /> PROPERTY Owner Quik Story Markets Address 4567 Enterprise Street Zip 94538 Phone# {5101 657-8500 <br /> C-57 Contractor GreggDrilling&Testing. Address 950 Howe Road City Martinez Zip 94553 LicA C57-485165 Phone# (9251313-5800 <br /> Consultant!Sub Cntr Horizon Enviroinmental Inc. Address—!!970 Wind lav Drive.Suite_5 0ty_EI Dorado Hills_Lic# PG 5307 Phone# (91 939-2170 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> [x]NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# ©OVER-BORE. DIAMETER <br /> [x]WELL# MW-1 0 PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: drill out existing MW-1 and replace with similar well <br /> T(PE.OF WELL INSTALLATION tYPE CONSTRUCTION SPECIFICATIONS <br /> [x]MONITORING [x]HOLLOW STEM DIA.OF BOREHOLE 8" []MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: 2" <br /> a EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OFFCCASING:p STEEL {x]PVC aOTHER: <br /> VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL _s -r TREM E TYPE tO BE USED: [x]AUGERS a HOSE <br /> a AIR SPARGE!OZONE lI PUSH POINT(GP or CPT)GROUT SEAL PUMPED: [x]Yes ' []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> []SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS neat cement � <br /> a OTHER: q OTHER APPROX.BORING DEPTH 75-- 86 ` x]BOLTED TRAFFIC BOX or a STOVEPIPE <br /> CONDUCTOR CASING PROPOSED no (if YES,list specifications in comment <br /> section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinanc 7sand Regulations, and all applicable Califarni State <br /> Signed x Title/Company Ed t <br /> 9 <br /> Print Name �� � � ` 3 Date Z' V <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 10 3 0 Sou 1 ' e- S+6enkigu , CA <br /> WORK ALAN DATED: hA a v 2. 2 O os <br /> Application Accepted 6 C Date Issued 1 2 b O 5 Area�1 459 _ <br /> Grout Inspection �—Date u 1 Final Inspection By ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS:- I C + ; YL <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 99.00 $9. 00 1­� s z?ros .SR# 0042-421 <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />