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05/23/2095 11 35 20946836'33 FIFTH FLOOR PAGE 02 <br /> r <br /> LL PERMIT APPLICATION FORM SITE <br /> nEM�i , CSAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 1.4, n 4 9005304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENMRONMENT HEALTH (209) 468.3449 <br /> PERMITISEMACES NON-REFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andfor install the work described This appllcaVon m made an cornphance with San <br /> Joaquin County Development Tdle Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> Assessors <br /> WELL Location 1030 South Olnce Street Gross Street EastMain City Stocldon Zap Parcel# 157-264-22 <br /> PROPERTY Owner Quikstogmarkats Address 4567 Enterpnse_StLeeL Zlp 94538 Phone# (510)657.85.0Q <br /> C-57 Contractor Gregg Drilling&Testing Address $"Howe Road Caty Martinez Zap 94553 Lir.# C57.4851e5 Phone# 1925)313 5a00 <br /> Consultant 1 Sub Cntr Honxan Enviro,nmental Inc Address 4470 Wmdolav_Dnv-e,Su11;e5Gty_EI Dorado Hiils_Lac* PG 5307 Phone# f91619"j22i70 <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NI NEW WELL/BORING (GPT GEOPROBE,HYDROPUNCH,HAND-AUGER OTHER') E7 DESTRUCTION (choose type below) <br /> a SOIL BORING# [1 OVER-BORE DIAMETER <br /> jx]WELL# MAJ [I PRESSURE GROUT <br /> p'Other GROUT SPECIFICATIONS <br /> COMMENTS dnll out exisbng MWA and replace with similar well <br /> TYKE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> (k]MONITORING Ut]HOLLOW STEM DIA OF BOREHOLE 8" Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA 2° <br /> []EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS Sch 44 TYPE OF CASING a STEEL [x]PVC ©OTHER <br /> [I VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 5o, TREMIETYPE TO BE USED [x]AUGERS a HOSE <br /> AMR SPARGE/OZONE o PUSH POINT(GP or CPT)GROUT SEAL PUMPED [x]Yes a No (NOTE. MAXIMUM FREE-FALL DEPTH IS 301) <br /> OIL BORING n HAND AUGER GROUT SPECIFICATIONS neat pefCont <br /> l)OTHER o OTHER APPROX BORING DEPTH 7 ' [x]BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED no (d YES,lat speelflcations an comment <br /> section) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4$WORKING HOURS NOTICE REQUIRED FOR INSPECTION& <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinanc s and Regulations,and all applicable Californip State <br /> S <br /> Signed x TiWCompany <br /> Print Name .51,c- r �-q— Dale Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS. 10 3 0 Sou fis 0 1 t.V A AYB n u eStock„ .. <br /> WORK PLAN DATED. Mail 2. 7-005- <br /> I <br /> Application Accepted By Date Issued__m .2,3 2d D 5 Area _ <br /> Grout Inspection By Date Final Inspection By Date_ <br /> Destruction Inspection By Date <br /> CpMMENTS I CONDITIONS 1 C • } <br /> ACCOUNTING ONLY Alp)# FAC# <br /> CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY I DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 357,01 89.06 j 9900 SR# 004 ,24 .Zq <br /> C-57— WC_-WArVER C-57 Letter of Authorization to sign permit—Encroachment doc 9/30/02 <br />