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n Joaquin County <br />FAC# <br />oo4�!N. <br />FEE INFO <br />EnviroTimental Health Department SITE <br />CHECK # <br />East Main Street, Stockton, CA 95202-3029 MITIGATION <br />DATE PERMIT / SERYICE REQUEST # <br />h�u(�0 <br />68-3449 Fax: (209) 468-3433 Web: www.-,jgov.org/ehd UNIT IV <br />�,�, Well Permit Application <br />KiAR I <br />140N -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />n <br />I install the described. This is made in with San <br />Application is rw'a 6,� County for to <br />❑EP9t]� _ aquin a permit construct and/or work application compliance <br />Joaquin County De'Vogprrier•Tt 4,!Cbaoter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />5 <br />Assessors <br />WELL Location e901 ci eSf l a ff Cross Street E. Harding Wav City Stockton Zip 9520.1 Parcel# 1 <br />2 -1•e9014 <br />PROPERTY <br />Owner Mill Creek Development Address 343 East Main St. Ste 318 city Stockton Zip 95202 Phone# 209-401-4102 <br />C-57 ContractorGregg Drilling and Testinddress 950 Howe Road City Martinez Zip 94553 Lic#485165 Phone# 925-313-0302 <br />Consultant / Sub Cntr URS Corporation Address 2870 Gateivav Oaks Dr Cit&erattiento Lic# Phone# 916-812-8037 <br />GIS Coordinates: X 'Y Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />BORING # 0 OVER -BORE. DIAMETER <br />(; <br />f� <br />,OIL <br />WELL # DMW-10, 11. 12. 13. and 14 0 PRESSURE GROUT <br />` <br />Q <br />0 "Other _ GROUT SPECIFICATIONS <br />COMMENTS: <br />WORK PLAN DATED: 1 �t 3 � C;' $ ( t>~- 14) l � � t ��(, a �-ti^ 1 5-1410.1- ('tpyww' to, <br />Application Accepted By 9^� y Date Issued <br />Grout Inspection By_ Date ____Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />FEE INFO <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE 8 in 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Lin _ <br />CHECK # <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: 0 STEEL 1XPVC 0 OTHER. <br />DATE PERMIT / SERYICE REQUEST # <br />p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Approx 40 ft TREMIE TYPE TO BE USED XAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: R Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />p SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS AgLI <br />0 OTHER 0 OTHER APPROX. BORING DEPTH at) t0 100 rt OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />5 <br />COMMENTS: Local Agenev Casc No 1882. Plcasc refer to work phut dated Febmin, 13. 2008 <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 inanc Regulatir' sA and all applicable California State Laws. <br />fir^ f Ct <br />Signed x _ 1 ��t \ Title/Company Senior Geologist/URS Corporation <br />Print Name Anthony Mindling _DateMarch 17 2008 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: -L Ok W, 5t (- ov" L' <br />WORK PLAN DATED: 1 �t 3 � C;' $ ( t>~- 14) l � � t ��(, a �-ti^ 1 5-1410.1- ('tpyww' to, <br />Application Accepted By 9^� y Date Issued <br />Grout Inspection By_ Date ____Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERYICE REQUEST # <br />INVOICE <br />[vc� SR# vos; G8 <br />C-57 ✓ WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br />L111329-02-001 WEB <br />9/11/2007 <br />