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n Joaquin County <br />Envirental 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 />SITE <br />MITIGATION <br />UNIT IV <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 />1901 SE1 Dorado Street Fifth Street Stockton 95206 Assessors 16508019 <br />S. WELL Location Cross Street City Zip Parcel# <br />PROPERTY <br />Owner Mohammad Matar Address 1901 S. El Dorado St City Stockton Zip 95206 Phone# <br />C-57 Contractor Gre/�gg Drilling Address 950 Howe Road City Martinez Zip 94553 Lic# 656407Phone# (925) 313-5800 <br />Consultant / Sub Cntrhd6V i.o+Cf�f Cts f:�V ik'a� Address Slli( k c i , c( City 3/ rf � Lic# 6 ��� 2 Phone# cy % -l0 i7 <br />(� <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />x,,VNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) _ <br />SOIL BORING # CPT -1 through CPT -3 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS Q1 <br />COMMENTS: Three on-site CPTs to total depth of 1201. <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 Ord,inances,,Rules and Regulations, and all applicable California State Laws. <br />V, <br />Signed <br />Print Name v /'!Lf%lLn <br />Title/Company Sf�1'I •-S�ie tbsl <br />DEPARTMENT USE ONLY <br />Ell <br />ate }Ci -0 <br />SITE MAP IN UNIT IV FILE, ADDRESS: I a o l S i_ I 1> o -wj-- s it , 5 ( v im <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />0 <br />_Date Issued t O3 Area <br />Final Inspection By - Date T 711' <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />DATE PERMIT / SERVICE ST # <br />0 MONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE 2 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />(*� <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL D PVC D OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL 120 TREMIE TYPE TO BE USED: 'AUGERS 0 HOSE <br />c' <br />C — <br />0 AIR SPARGE/ OZONE <br />� PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />]a SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS Type II Portland Cement <br />0 OTHER:_0 <br />OTHER <br />APPROX. BORING DEPTH 120' 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 Ord,inances,,Rules and Regulations, and all applicable California State Laws. <br />V, <br />Signed <br />Print Name v /'!Lf%lLn <br />Title/Company Sf�1'I •-S�ie tbsl <br />DEPARTMENT USE ONLY <br />Ell <br />ate }Ci -0 <br />SITE MAP IN UNIT IV FILE, ADDRESS: I a o l S i_ I 1> o -wj-- s it , 5 ( v im <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />0 <br />_Date Issued t O3 Area <br />Final Inspection By - Date T 711' <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 ST # <br />INVOICE <br />0- <br />Z6 q5- <br />C-57 -/ WC_Z- WAIVER_ C-57 Letter of Authorization to sign permit ncroac ment doc <br />EHD 29-02-001 WEB <br />9/11/2007 <br />