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San Joaquin County <br />4;1 Environmental Health Department <br />-A <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />OP9) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />SITE <br />MITIGATION <br />UNIT IV <br />SEP 2 7 2006 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to Sanjoaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />JoaqutNVfffDki�+4Ehapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />pp���� Assessors 110-210-04 <br />WELL LAtitl11'�� OL1rt Cross Street N. Pershing City Stockton Lip 95207 Parcel# <br />PROPERTY 95267- (209) 478-2060 <br />Owner Stockton Hospital LP Address PO Box 7343 City Stockton Zip 0343 Phone# <br />Cascade Drilling Inc. t£3 Itdv\eko <br />C-57 Contractor Address d OMs2 L Citi rC�e City CnrQ6,rA Zip `1 S 1�1; uc# 1 t7510phone#_ (916) 638-1169 <br />2285 Morello Ave. Pleasant (925) 602-4710 <br />Consultant / Sub Cntr_ ETIC Engineering, Inc. _Address City_ Hill, CA Lic# Phone# <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING <br />0 SOIL BORING #_ <br />0 WELL # <br />0 *Other <br />COMMENTS: <br />,Y <br />Townsh <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />Range <br />Section <br />R DESTRUCTION (choose type below) W <br />JJOVER-BORE. DIAMETER- 1'10" to 3 ft bes ^� <br />&PRESSURE GROUT �J <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /># MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE, 10" - 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 4"-- <br />0 <br />"_0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL Q °VC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 44' 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 prep ed this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules an egulations, and all applicable California State Laws. <br />Ca- L r�� <br />Signed x__ _ Title/Companv Ca.` �`-�`�-"— C)" ' 1 r <br />Print Name e rvve-s-�' Date (R a C) —fib <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Ll q(I' f f-L'I-t, I —,2 <br />WORK PLAN DATED: <br />Application Accepted By. /ice= '' Date Issued 9� 1� �' Area `� <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By nn.> - Date / oil L nom' <br />COMMENTS / CONDITIONS: (-' S - <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE / SERVICE REQO"T-k VOICE <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_ En orc a'chmetstttac <br />EHD 29-02-001 <br />6/22/04 <br />11 <br />