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�D SAN JOAQUIN COUNTY <br /> ENANMENTAL HEALTH DEPARTM& SITE <br /> ` 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209) 468-3449 Fax: (209)468-3433 Web:www.s' ov. IV <br /> a <br /> r <br /> WELL PERMIT APPLICATION h,AY 17 dil) <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IaWIRON,NIEdNjTq qHp 7'l� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appl�.TjSgn.�d�19plhCt with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health�de��ra7�rMirsB(CAssessor'slJ <br /> (City of Stockton ROW) ryp <br /> Well Location east aide of Turnpike Road Cross Street S. Lincoln Stieet City Stockton Zip 95106 Parcel# <br /> Property <br /> Owner City of Stockton Address 22 E. Weber Ave. City Stockton Zip 95202 Phone# 209-937-841 <br /> C-57 Contractor All Well Abandonment Address 3609 Pleasant Valley Rd City Placerville LIC# 846359 Phone 600-946-1355 <br /> ConsultantlSub Cntmdvaneed oeoEnvironment Address 837 Shaw Road City Stockton Lie# 95215 -51 - 3 <br /> GIS Coordinates:X ,Y ,Township Range a ctio <br /> WORK TO BE PERFORMED: DESTRUCTION(CHOOSE TYPE BELOW) <br /> ®NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) ❑OVER-BORE DIAMETER <br /> ❑SOIL BORING# ❑PRESSURE GROUT <br /> Z WELL# mw-i 2 GROUT SPECIFICATIONS <br /> ❑`OTHER <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ®MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 8 n ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:2 a° <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS Schd. 40 TYPE OF CASING:❑STEEL EIPVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 50' TREMIE TYPE TO BE USED❑AUGERS®HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:El Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Portland Type II <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 65' ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED— (if YES,list specifications in comment section) <br /> COMMENTS: f ffInc1 f Agowf h d ti,n at Looea Pc.ectV, 160' `K—ikQ Road. <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,and all appli able a rma Laws. <br /> Signed Title/Company Project Scientist <br /> Print Name Ally Co avita Date 04/28/10 <br /> DEPARTMENT USE ONLY f (� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: L/ � U / —T / DI -Road <br /> o a d `�'h Ck J f D rl <br /> WORK PLAN DATED: `/ S� 1 eYribe—Y ,200 <br /> APPLICATION ACCEPTED BY V f -SOY i r' M� llitri-n DATE ISSUED AREA 14�5�9� <br /> GROUT INSPECTION BY IIS ti^-n"-- FINAL INSPECTION BY U DATE b lzb <br /> DESTRUCTION INSPECTION BY 1 I� DATE <br /> COMMENTSICONDITIONS: riS {ILEI Irn-r AT" <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES EE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 350 3 3s o� 434, 00 3/ 037n s'l8-/� SR# 00 S-179& <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHD 2"1 1115107(WEB) <br />