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LL PERMIT APPLICATION FRM ECl''IEI SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />4 J005304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />ENVIRONMENT HEALTH <br />PERMIT/SERVICES 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 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 1030 South Olive Street Cross Street East Main City Stockton Zip Parcel# 157-264-22 <br />PROPERTY Owner Quik Stop Markets Address 4567 Enterprise Street <br /> <br />Zip 94538 Phone# (510) 657-8500 <br /> <br />C-57 Contractor Gregg Drilling & Testing Address 950 Howe Road City Martinez Zip 94553 Lic# 057-485165 Phone# (925)313-5800 <br />Consultant/ Sub Cntr Horizon Enviroinmental Inc. Address 4970 Windplay Drive, Suite 5 City_El Dorado Hills Lic# PG 5307 Phone# (916) 939-2170 <br />GIS Coordinates: X , Y Township <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED: <br />[x] NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />I] SOIL BORING # <br />[x] WELL # MW-1 <br />1:1"Other <br />COMMENTS: drill out existing MW-1 and replace with similar well <br />0 HAND AUGER GROUT SPECIFICATIONS neat cement rft <br />OTHER APPROX.BORING DEPTH 75"-- 56 Lx] BOLTED TRAFFIC BOX or ['STOVE PIPE <br />CONDUCTOR CASING PROPOSED no (if YES, list specifications in comment <br />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 Ordinanc RU s and Regulations, and all applicable Californi State <br /> Title/Company (o) <br />Print Name ??k-'( 51\f("1_ ? . S3 0 3-- <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1030 Sou-i-k Olive AY antic <br />fl DESTRUCTION (choose type below) <br />0 OVER-BORE DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />[x] MONITORING <br />B EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE/ OZONE <br />0 SOIL BORING <br />0 OTHER: <br />Signed x <br />Date <br />Stock-I-0)-v CA <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[x] HOLLOW STEM DIA. OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2" <br />0 AIR HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: 0 STEEL [x] PVC 0 OTHER: <br />0 MUD ROTARY ' ' riL t'P DEPTH OF GROUT SEAL „50' TR M E T P_ 0 BE USED: [x] AUGERS 0 HOSE K- <br />0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: [x] Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') ""••• <br />WORK PLAN DATED: MG1 y 2 1 ZOOS <br />Application Accepted piy V r McCartney Date Issued <br />Grout Inspection By'rti CIM,/,// Date Jo k„r_. I )2 r Final Inspection By <br />Date Destruction Inspection By <br /> <br />Area 1459 <br />ate <br />DITIONS: a+ i )-1 -P,r realaaern€Y1f WIOn; +0r; well MW- I , - - ---- - _ <br />ACCOUNTING ONLY AID# <br />. <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE RT4 INVOICE <br />3501 89.00 g 9. 00 sR# 004 24 29 <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachmerrr <br /> <br />9/30/02 <br />