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,o. 4 A.... can Joaquin County <br /> a Envilmental Health Department • SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgq}g/el 0 UNIT IV <br /> tift'`'Foggy Well Permit Application �[ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 011 <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 Location 1607 Turnpike Road Cross Street Lincoln City Stockton Zip 95206 Parcel# 165-040-04 <br /> PROPERTY <br /> Owner GAUT GREGORY A & PAULETTE Address 1R12o ARRTcoNF WAY City LINDEN Zip95236 Phone# (209)466-4601 <br /> O-57 Contractor r:rPgg D ill ing Address 950 Howe Ave. City MarrinP2 Zip 94553LIC# 656407 Phone# (925)313-5800 <br /> Consultant/Sub Cntr Advannee Address_ P17 .er,a,., Pd City Stockton Lic# 6an227 Phone# (209)467-1006 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> a.NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# B-5 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:IL& <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL SFC-TD TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 11 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FAI/ DEPTH IS 30') <br /> R SOIL BORING aHAND AUGER GROUT SPECIFICATIONSSypo IT Portland <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 70-120' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES, list specifications in comment section) <br /> COMMENTS: BORING LOCATION IS A_PAIRED BORING• OFF-SITE INVESTIGATION FOR LOPEZ PROPERTY <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 Ordinances) Rules and-Regulations I and all applicable California State Laws. <br /> Signed 1. Title/Company Staff Scientist BE ICJ'( "2;111F L <br /> Priht Name Al igon rol a.ri ra Date 08/20/08 <br /> DEPARTMENT USE ONLY AIJ % 2 h <br /> SITE MAP IN UNIT IV FILE, ADDRESS: I ( o I TU r n jQ; k e '}Z o o d EiNVIRO [AIEN 1 HEALTH <br /> WORK PLAN DATED: M a)/ 2 . a O Q R -r 1/'bLhVIUFT- <br /> Applicationion Accepted By C'{- i a, 1-. M ou 'a r'I-n e 4 Date Issued Ll q V S t 22, -200 8 Area 14.5 9 <br /> Grout InspectionBy Y;!'i'I7fY id "L 0766rb%r Date c?-5-r4B Final Inspection By 1 )nd & Date '-r-08 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: - -F )1, 0 '7 TtLrn , Ce R <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 5EC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35D3 315.60 404- 00 324L '-z/M 822 0,9 SR# 0D5-r-Z'l0 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />