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�!N n Joaquin County <br /> N °y` <br /> Envirthental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> o <IFo' 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 /> Assessors <br /> WELL Location 1601 Turnpike Rd. Cross Street Lincoln City Stockton Zip 95206 Parcel# 165-040-13 <br /> PROPERTY <br /> Owner LOPEZ, NEREIDA P Address PO BOX 6569 City Stockton Zip 95206 Phone#209-944-4523 <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez Zip 94553 Lio#656407 Phone# 925-313-5800 <br /> Consultant/Sub Cntr Address a37 PA CityStockton Lie# 6an227 Phone# (209)467-1006 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> g NEW WELL/ BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER`) D DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> ItWELL# MW-9,MW-10,MW-11 FILE COPY aPRESSURE GROUT <br /> p`Other GROUT SPECIFICATIONS <br /> COMMENTS: _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ff MONITORING ff HOLLOW STEM DIA.OF BOREHOLE 8" D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2" <br /> a EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS SCHD 40 TYPE OF CASING: a STEEL H PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 50-105' TREMIE TYPE TO BE USED: ffAUGERS a HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ELYes a No (NOTE: MAXIMUM FREE-FA/ / DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Portland Type II <br /> u OTHER:_0 OTHER APPROX.BORING DEPTH 65-120' g BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED na (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4U WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances I Rules ndRegulations, and all applicable California State Laws. <br /> Signed z�i� Title/Company Environmental Scientist <br /> Print Name Ally Colavita Date 8/7/7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 1t. 0 I '1U rn <br /> WORK PLAN DATED: May 21 oo '7 <br /> Application Accepted By y i C14-n r i b L. M e.C'a r+new Date Issued 8 /FL I O Area <br /> Grout Inspection By Vr64br;&Yne..('*rFh¢. U <br /> r Date 8f)3ro7 Final Inspection By U1i�-o��k G �6YIyr.Pt,Date f — �S� 7 <br /> Destruction Inspection By Dat <br /> COMMENTS I CONDITIONS: :L "l- - 11 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES 11 FEE INFO AMOUNT REMITTED CHECK# 5EC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 35U I 29 38 3 o p zs6zs �iY�t 8-8.0'1 SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br />