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�q�'^' <br />:.•..••.c� <br />� <br />San Joaquin County <br />0- <br />Environmental Health Department <br />0 AIR HAMMER/DRIVEN <br />600 E. Main Street, Stockton, CA 95202-3029 <br />0 VAPOR <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.org%ehd <br />DEPTH OF GROUT SEAL 3 3 feet TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />Well Permit Application <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes ff No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <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 />Stockton 95202 Assessors <br />WELL Location 545 East Miner Ave Cross Street American City Zip Parcel# 139-240-12 <br />PROPERTY <br />Owner Don McPhillips Address 545 East Miner Ave GIN Stockton Zip 95202 Phone# 466 2568 <br />C-67 Contractor Drilling Address 7900 Myrtle Ave. City Eureka Zip 95503 Lic# G72617Phone# (707) 444-9040 <br />ACS 837 Shaw Road Stockton 680227 209 467 1006 <br />31-145(p <br />Consultant/ Sub Cntr Address CityLic# Phone# <br />GIS Coordinates: X J1 - 1Q 45( 0 Y—III. 01'.. Township Range Section <br />WORK TO BE PERFORMED: <br />VIEW WELL/ BORING ( GEOPROBE, HYDROPUNCH. HAND -AUGER. OTHER') p DESTRUCTION (choose type below) <br />0 SOIL BORING #_ 0 OVER -BORE. DIAMETER____ <br />0 WELL #MW -"AA <br />V V /PRESSURE GROUT <br />O'Other � GROUT SPECIFICATIONS <br />COMMENTS: <br />PETIT <br />MONITORING <br />INSTALLATION TYPE <br />HOLLOWSTEM <br />STEM <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 8 " 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Two <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS Schdle 40 TYPE OF CASING: 0 STEEL )TPVC BOTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL 3 3 feet TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes ff No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS Portland .► MeA-37 <br />0 OTHER: <br />Il OTHER <br />APPROX. BORING DEPTH 42 feet 8 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: Soil <br />samples - for monitoring well installation <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 Ordjpamesrule�s-a��d Regulati ns, and all applicable California State Laws. <br />Vice President/AGE <br />Signed x // G Title/Company <br />Print Name "fobelt E. Marty / Date_ 20 August 2007 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 545 East Miner Ave <br />WORK PLAN DATED: 07 December 2006 <br />Application Accepted By. <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS I CONDITION <br />/ n •.,�, <br />Date Issued t 4� Area e419 00 <br />_Date Final Inspection A -"--Date <br />Date <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />D <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />Rill BY <br />DATE I SERVICE ST # <br />INVOICE <br />350 <br />s <br />383. <br />Z(v09 ( <br />8.28. sR 51 <br />C-57 V WC V -WAIVER_ C-57 Letter of Authorization to sign permit ✓ Encr—oa­chittenirdocLIV/11 <br />END 29-02-001 web <br />6/22/04 <br />