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,-an Joaquin County �� <br />Environmental Health Department �F�SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ®� 2[JU� MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjg&-.> i'' ihd.'%'l 1VTHE 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 />Assessors <br />WELL Location Landscaped area,City of Stockton R -o -w on Cross Street Monroe Ave. City Stockton Zip 95204 Parcel# NA <br />North side of Harding Way across from 244 W.Harding Way <br />PROPERTY <br />Owner City of Stockton Address 22 E. Weber Avenue City STOCKTON Zip 95202 Phone# (209) 937-8411 <br />C-57 Contractor Gregg Drilling Address 950 Howe Ave. City Martinez Zip 94553Lic# 656407 Phone# (925)313-5800 <br />Consultant/ Sub Cntr Advanced GeoRnvironmentalAddress A-�7 ,Shaw Rr3 City Stockton LIc# 680227 Phone# (209)467-1006 <br />GIS Coordinates: X 'Y , Township Range Section <br />WORK TO BE PERFORMED: <br />B NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />USOILBORING# B-7,3-8 DOVER -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: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL RFC, -TD TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE ItPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FAI / DEPTH IS 30') <br />ff-SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Type TT Pnrtl anrd <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 25' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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 I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances Rules and Regulations) and all applicable California State Laws. <br />Signed x �� p �-' ' Title/Company qt- aff F.nvi rnnmanYal Ari anti qt- <br />Print <br />f <br />Print Name Al ; son CnJ avi to Date g ir, inz <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ZOO La l o e k of d ct rl ; a a WG (4 <br />WORK PLAN DATED: Jan L)a Ll .2 3 - 200 'l <br />Application Accepted /By V)'6 -("o r ' L . /Yl C r -F Date Issued b Area S <br />Grout Inspection By V Lc4:4 c10 L-. Xd6jj4g,� Date G 1 Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: .T 63 "2 and 0-,q <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />5EC'D BY <br />DATEPER RE INVOICE <br />35-0 / 89 DD <br />350 3 z8 . vo <br />374. D� <br />2574 / <br />SR# 00 S08 G� <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroac men oc_ <br />EHD 29-02-001 <br />6/22/04 <br />