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San Joaquin County <br />Environmental Health Department o SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />52 C`MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd _ UNIT IV <br />: Y 9 �00 <br />47`/Foa"- Well Permit Application <br />'`JlRUNMIEPJ1 HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED5F-pC /fir /l rc <br />,0ES <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 />Assessors <br />WELL Location 2122 S. Airport Way Cross Street E. 8th St. City Stockton Zip 95206 Parcel# 169-162-01 <br />PROPERTY <br />Owner Ralph Lee White Address 2203 S. Airport Way City Stockton Zip95206 Phone#. <br />C-57 Contractor Gregg Drilling Address 950 Howe Rd. City Martinez Zip94553 Lic#'{g;ib5 Phone# (983)313-5800 <br />Consultant/ Sub Cntr Advanced GeoEnvironmentai Address 837 Shaw Rd. City Stockton Lic# 680227 Phone# (209)467-1006 <br />GIS Coordinates: X <br />WORK TO BE PERFORMED: <br />gNEW WELL / BORING <br />$ SOIL BORING # C <br />0 WELL # <br />0 *Other <br />COMMENTS: <br />Townshi <br />Range <br />Section <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />-1 0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2 Q 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 100 ' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE g PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />$SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Type I/II Portland Neat Cement <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinan , IQs, and egulations, and all applicable California State Laws. <br />Signed x Title/Company Vice President/ Advanced GeoEnvironemental <br />Print Name Robert Marty Date 08 May 2007 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By \ �c r i Date Issued S/2 ��G Area L� Z <br />Grout Inspection By L�. �tn�n�� Date S 2 D Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />L Sblo� <br />(tit <br />SLS�Os� <br />SR# <br />35-0 <br />-$( 2-FSS1•CiC <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 <br />6/22/04 �� /\ <br />