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n Joaquin County <br />Enviro mental Health Department <br />600 East Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />MITIGATION <br />!.GAJ 0 2CI1WIT IV <br />ENVI S�:1i'9i1�i i ALI,I <br />PEP"�.lil.T/sEgv!Cr rz <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 />Cit of Stockton Right of Way s. El Dorado/Fifth St Stockton 95206 Assessors r� <br />WELL Location y g y Cross Street City Zip Parcel# <br />PROPERTY 345 N. E1 Dorado St <br />Owner City of Stockton Address City Stockton Zip 95206 Phone# <br />Adv GeoEnvironmental <br />C-57 Contractor Address <br />837 Shaw Road Stockton 95215 C57-660227 (209)467-1006 <br />City Zip Lic# Phone# <br />PE CODES <br />Consultant/ Sub Cntr jVaWed ddress i5'3_1 S/1Cit Ki':7t City �CGk'fZ✓y' Lic# 7 Phone#w <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />GIS Coordinates: X Y <br />Township Range Section <br />'SY°3 <br />SR. <br />Y,z,•�J <br />WORK TO BE PERFORMED: <br />SR# <br />x..UNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />xgSOILBORING#B-5 thru B-8 <br />DOVER -BORE. DIAMETER <br />C%J <br />0 WELL # <br />0 PRESSURE GROUT' <br />0 *Other <br />GROUT SPECIFICATIONS <br />Four off-site soil borings <br />to depth of approximately 401. 3 borings along E1 Dorado; 1 on Fifthly <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM <br />______0 <br />DIA. OF BOREHOLE 1.511 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA ------- <br />111 <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY <br />DEPTH OF GROUT SEAL 401 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE -fl PUSH POINT (GP or CPT)GROUT <br />SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />13 SOIL BORING 0 HAND AUGER <br />GROUT SPECIFICATIONS Type II Portland Cement <br />0 OTHER:_0 OTHER <br />APPROX, BORING DEPTH 40 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENT <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 Ordi ances, Rule nd Regulations, and all applicable California <br />cState <br />-/Laws. <br />Signed x �/ Title/Company J�,-tC Je_ielt *,S <br />Print Name / "(a "mc Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: I Cl o l S tF I t)dra .L- 5Ly- -44� <br />WORK PLAN DATED: - uti- I Zoo I - <br />Application Accepted By���r Date Issued !9 g Area �.0 t <br />Grout Inspection By Date Final Inspection By Date 7. -zz ng <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />'SY°3 <br />SR. <br />Y,z,•�J <br />SR# <br />C-57PWCC/WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br />EHD 29-02-001 WEB <br />9/11/2007 <br />