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San Joaquin County `1 <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> NONREFUNDABLE 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 Location145 South Sutter St Gas Street Washington Cfly Stockton Zip 95202 parcel#Q1z499-15-024 <br /> PROPERTY�t- O�'S7yc�{ A9dress.yZ s/V �� bor�(OCIryStockton Zjp95202 Phone# y ? - - -fC� <br /> Owner_—Y <br /> esa3195 Lu Dr Rancho 95742 819548 (916)638-5564 <br /> C•57 ContractorW t Hzmat Address3195 CltyCordova Zip Llc# Phone# <br /> 1340 Treat Blvd Walnut 522739 (925)948-2655 <br /> Consultant/Sub CnbWeston Solutions Addresser+ -i0 Cty Creek Uc# Phone# <br /> GIS Coordinates:X 4201623 y_650633 UTM10S Township 01 North Range 06 East Section 20 L <br /> WORK TO BE PERFORMED: <br /> K <br /> NEW WELL/BORING (CPT, EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> `OIL BOR(pl # p OVER-BORE. DIAMETER <br /> ELL# 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �-1 I <br /> VONITORING fiOLLOW STEM DIA.OF BOREHOLES 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: oL <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS&6,40 TYPE OF CASING: 0 STEEL PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUP SEAL T b D TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE1 OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> p OTHER: N OTHER APPROX.BORING DEPTH I�aLO )WtOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASJNG PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: dN <br /> PG�.'�'C /.n/(- ��A rs'A G'�O k-f" ��tn .�'�vivl t/11-v(it ✓1-41� <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 Ordinances, Rul5k and Regulations,and all applicable California State Laws. <br /> Sgnedx - Title/Company Project Manager, Weston Solutions, Inc, <br /> pftNarrreThomas Fortner Date June 2, 2008 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: 365 <br /> FIEF flfiff <br /> Application Accepted By Date Issued L, 13 /O�—Area <br /> Grout Inspection By -ti(' n....r 0-` Date O`rl Final Inspection By 1 ""*^ Date 9/1 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: C — row I�InS <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEEINFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 So) SR# <br /> C-57 : WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29 02-001 WEB A c 1/F, / (>t - '—e—� P Yw'�- 2c-'- l t <br /> 9/11/2007 <br />