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SAN JOAQUIN COUNTY <br /> n c� ENSONMENTAL HEALTH DEPARTOT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax.(209)468-3433 Web:www.sogov.org/ehd 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 /> Assessor's <br /> Well Location 1137 S. Stockton St. Cross Street Navy Drive City Stockton Zip 95206 Parcel# 163-260-22 <br /> Property <br /> Owner PHILLIPS, JOHN B & BONNIE AAddress 1133 BRISTOL AVE City STOCKTON Zip 95204 Phone# (209)944-0909 <br /> C-57Contractor ADVANCED GEOEWIRONMENTAL Address 837 SHAH ROAN city STOCRTON Zip 95215 LIC# 680227 Phone <br /> Consultant/Sub Cntr SAME AS ABOVE Address City Lick_Phone (209)467-1006 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> El NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> EISOIL BORING# B-1 through B-10 ❑OVER-BORE DIAMETER <br /> ❑WELL# FILE COPY ❑GROUT SPECIFICATIONS <br /> OUT <br /> El*OTHER <br /> COMMENTS: <br /> Vy� � <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: NA <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS NA TYPE OF CASING:❑STEEL ❑FVC ❑ OTHER NA <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 10' bS9 TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE IS PUSH POINT(GP OR CPT) 10 GROUT SEAL PUMPED:❑Yes IN No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ®SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS PORTLAND TYPE II <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10'bsg ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> CONDUCTOR CASING PROPOSED (RYES,list specifications in mmmenl 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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a e I appli Ne CSI" ornia Laws. <br /> Signed 0 Title/Company VICE PRESIDENT <br /> Print Name ROBEAT MARTY C Date 05/19/09 <br /> DEPARTMENT USE ONLY FILE CCP Y <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY Ut-Ar�c-- DATE ISSUED 9/" O AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE bl <br /> DESTRUCTION INSPECTION BY DATE <br /> COM M ENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> LP E CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> zgor $ 89.00 2q-�as !f0 I S ss'o9 SR# 574 It <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHD 29-01 1115N7 <br />