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San Joaquin County <br />Environmental Health Department <br />C <br />����st Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />AUG 2 2 2007 Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />0 <br />--ORIGINAL <br />'I' <br />SITE <br />MITIGATION <br />UNIT IV <br />Application is heW thg9Ntl 6TJ 'ffiunty for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin County De *TYMN\A%gr 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location 1113 S. E1 Dorado St Cross Street E. Jackson St City Stockton Zip Parcel# 147-190-07 <br />PROPERTY <br />Owner Richard Northcutt Address3547 Bluelake Circle City Stockton Zip95206 Phone# <br />C-57 Contractor Gregg Drilling Address 950 Howe Ave City Martinez Zip94553 LiC#656407 Phone# (925)313-S800 <br />Consultant/ Sub CntrAdv GeoEnvironmental Address 837 Shaw Road City Stockton Lic# Phone# 467-1006 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # CPT- 9 0 OVER -BORE. DIAMETER <br />0 WELL #' C„ „ J a PRESSURE GROUT r <br />0 *Other �/7 GROUT SPECIFICATIONS <br />COMMENTS: --- <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STF1111 DIA. OF BOREHOLE 2 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 ROTARYEPTH OF GROUT SEAL 200' TREMIE TYPE TO BE USED: $] AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE PUSH POINT (GP o PT ROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') O <br />SOIL BORING HAND AUGER GROUT SPECIFICATIONS Type II Portland <br />0 OTHER:0 OTHER APPROX. BORING DEPTH 200 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 />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 Ordinan lgu�and Itegulations, and all applicable California State Laws. <br />Signed x � Title/Company Vice President <br />Print Name Robert Marty Date 08-21-07 <br />DEPARTMENT USE ONLY <br />77 -77SITE MAP IN UNIT IV FILE, ADDRESS: �v S' !'Oy <br />WORK PLAN DATED: l21Z9 <br />Application Accepted By Date Issued W fg-"-at"W�M%. Area c- - <br />Grout Inspection By D Final Inspection By - Date /0—/0-0 <br />Destruction Inspection By Date - <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />S z sR#p l �Z[ <br />INVOICE <br />z <br />38'3._ <br />260 3 <br />C-57 WC= WAIVER_ C-57 Letter of Authorization to sign permit Encro/emen oc <br />EHD 29-02-001 <br />6/22/04 <br />