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San Joaquin County <br />Environmental Health Departm,, t, SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA'r95a`Jf ]�,V/IU1 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />l- Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATIt f, fl,v!Ef JT H ALTH <br />101-Q. <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Thf�appYicetio4 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 4716 E ST RT 88 HWY Cross Street Cherryland Ave City Stockton Zip 95215 Parcel# 101-021-23 <br />PROPERTY <br />PE CODES <br />Owner BAUMBACK ARCHIE Address 644 GLEN OAK DR City LODI Zip 95242 Phone# 209-334-3188 <br />AMOUNT REMITTED <br />C-57 Contractor Mitchell Drilling Address 7900 Myrtle Ave City Eureka Zip95503 Lie# 672617 Phone# 707-444-9040 <br />5EC'D BY <br />Consultant/Sub Cntr Advanced GeoEnvironmental Address 837 Shaw Rd. Citygtoc-kton LIC# 680227 Phone# 209-467-1006 <br />INVOICE <br />GIS Coordinates: X Y Township Range Section <br />.4 "-dam <br />z .00___4 <br />WORK TO BE PERFORMED: <br />2�2� f SR#ee, - _7 <br />:�) <br />[[NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />- <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />— <br />gWELL# MW-11,MW-12,MW-13,MW-14 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />15 MONITORING gHOLLOW STEM DIA. OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _2 <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCD 40 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 60TREMIE TYPE TO BE USED: (fAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FA/ / DEPTH IS 30'� <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Type II <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 85' 0{BOLTED TRAFFIC BOX or 0 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 I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances,les apd RegulationsI and all applicable California State Laws. <br />Signed x Title/Company Staff Scientist/Advanced GeoEnvironmental <br />Print Name Allv Colavita Date n2/19/n8 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 4Y FK fr o� i6 a <br />WORK PLAN DATED: loll 9 Ib 7 <br />Application Accepted By Date Issued 21-- 1 2-1 Area <br />Grout Inspection By a% Date 3 0 16 Final Inspection By ca, Date <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 />5EC'D BY <br />DATE ERMIT / EQUEST # <br />INVOICE <br />3s-/ <br />o <br />.4 "-dam <br />z .00___4 <br />G <br />2�2� f SR#ee, - _7 <br />:�) <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit ✓ Encroacoc✓ <br />EHD 29-02-001 <br />6/22/04 <br />