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San Joaquin County <br />Environmental Health Department <br />{ 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />r Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <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 />Port Road 21 + Port Road M Stockton 95201 Assessors t45636 <br />WELL Location Cross Street City Zip Parcel# `ii I <br />PROPERTY <br />Owner Port of Stockton Address2201 W. Washington St City Stockton Zip 95201 Phone# (209) 946-0246 <br />C-57 Contractor RSI Address220 N East Street City Woodland Zip Lic# 802334Phone# (530) 668-2424 <br />Consultant / Sub CntrWGR, Southwest, Inc. Addres515 W Pine st ste 8City Lodi Lie# Phone#209.334.5363 <br />GIS Coordinates: <br />Y <br />Township <br />Range. <br />Section <br />WORK TO BE PERFORMED: <br />lyNEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) 0 DESTRUCTION (choose type below) <br />[YSOIL BORING # 5 0 OVER -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: NA <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALapprox. 13' TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br />0 AIR SPARGE/ OZONE &PUSH POINT (GP or CPT)GROUT SEAL PUMPED: $ Yes 0 No (1 07E: MAXIMUM F5 EE -FA/ / DEP7H IS 30') <br />ffcSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Cement <br />0 OTHER:_G OTHER APPROX. BORING DEPTH 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 />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 Ordin nces, Rules and Regulations, and all applicable California State Laws. <br />Signedx��'^�� "~' Title/Company Project Manager/WGR Southwest, Inc. <br />Print Name Steve Brumm Date March 16, 2007 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: a?6 l�-u <br />WORK PLAN DATED: 311 <br />d <br />ryl <br />Application Accepted By / l' Date Issued_ <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />Date AD <br />r%,_ <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />/ L <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT ERVICE REQUESTS INVOICE <br />SR# SDIb`� <br />C-57 ✓ WC ✓ -WAIVER_ C-57 Letter of Authorization to sign permit / Encroachment doce✓/►'a <br />EHD 29-02-001 <br />6/22/04 <br />