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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 SITE <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd 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 app/ cation is made in compliance with San <br />Joaquin County Development TRIe. Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br />Assessors <br />WELL Location _San Joaquin River, R0404_Cross Street _Manthey at Houston City _Stockton_Zfp _95231_Parcet# <br />PROPERTY Owner_DWIZRD 404 -Address -235 East WeberAvenue_PO Box 1461_City_Stockhm_23p_95201-1461_Phone# 209.465.5883_ <br />C-57 Contractor_Gregg 1r? -Situ Address_950 Howe ROW City_Marb7rez ZtP_94553_Uc# 485165_Phone#_925.313.5800 <br />Consukant I Sub Cntr_Fu9m West Inc ._A idrsssf1000 Broadway, Suite 440 Cky_Oakland Lich_742013__Phorw#-510.268.0461_ <br />GIS Coordinates: X_See attached_. Y Township Range Section- <br />WORK <br />ection <br />WO K TO of PERFORl1ED: <br />Ixl NEW WELL ! BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) g DESTRUCTION (choose type below) <br />[Xi SOIL BORING # U OVER -BORE. DIAMETER <br />VQ WELL #_See attached work plan 11 PRESSURE GROUT <br />P•O"W GROUT SPECIFICATIONS _1111inommwneat cementl`jc,-�*17, f <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[21 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE_!"_ 13 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />u EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC o OTHER: <br />0 VAPOR Pq MUD ROTARY DEPTH OF GROUT SEAL -FLA] Depth TREMIE TYPE TO BE USED: PQ AUGERS Pq HOSE <br />0 AIR SPARGE! OZONE [231 PUSH POINT (GP or CPT) GROUT SEAL PUMPED. p() Yes Q No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />[a1 SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS 4 -sack mix neat cement with bentonite (941bs cement per 7.5gat H2O, 6% BerMonite_ <br />U OTHER: 13 OTHER APPROX. BORING DEPTH -1001 Pq BOLTED TRAFFIC BOX or PQ STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, fist specifications In comment section) <br />COMMENTS ---3f Points of Exploration (23CPT, 8 Borings) tbrtevee investigation, 2 monitain9 welts as needed to be installed adjacent to select borings _ <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING FLOURS 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 <br />Joaquin CQpnty Ordinan ules nd Regulations, and all applicable California State Laws. [' <br />Signed x ( Title/Company tawJ C.Tr.t AIG �A �t r1 h/11 ve 5-T <br />Print Name (' lift TF J 1 i3tiL�- Deia i z `z'f lJ� <br />v�r�+Ic r min r arvc vr.� r <br />SITE MAP I <br />Application Accepted By F" Date Issued Z� 6 -LO -7Ates <br />Grout Inspection BY , — <br />Date Final Inspection By Date <br />Destruction Inspection By Date r 4'e <br />/ <br />COMMENTS / CONDITIONS: A 2 -CM { -t!'S J7 C Clh �1 S4.4 CTe <r• c" a rd S <br />y.,/� N -� rr FACS P <br />INVOICE <br />COU_-N7TIONII: d5VT `� i �% /� <br />PE CODES FEE INFO U a•� 1p <br />REMITTED SERVICE <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encr%?HFAM d%.,,,,- <br />() (l, c vLK'� W ea P(Zfy " <br />J <br />