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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br /> <br />ORIGINAL <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />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 UST #3 Port Road 13 Cross Street G Street City Stockton Zip 95201 Parcel* <br />PROPERTY <br />Owner Port of Stockton Address2201 W. Washington Stcity Stockton Zip 95201 Phone* (209 ) 946-0246 <br />C-57 Contractor Address City Woodland zip RSI 220 N East Street Lic# 802334phone# (530) 668-2424 <br />WGR Southwest, Inc (209) 334-5363 Consultant/Sub Cntr Address <br />315 W Pine Ave Ste EL <br />ity Lodi Liao Phone* <br />GIS Coordinates: X <br /> <br />, Y Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />a NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />o SOIL BORING # a OVER-BORE. DIAMETER <br />R WELL # MW3 -7 fl PRESSURE GROUT <br />O *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />ii MONITORING If HOLLOW STEM DIA. OF BOREHOLE 10 " a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 4" <br />a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 0.02" TYPE OF CASING: a STEEL a PVC 0 OTHER: <br />O VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 6 ft TREMIE TYPE TO BE USED: a AUGERS ['CHOSE <br />D AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (1 07E: MAXIMUM F5 EE-FA/ / DEP7H IS 30') <br />O SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Portland cement <br />O OTHER: a OTHER APPROX. BORING DEPTH 30 ft cf BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED No (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />4U 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 Ordinapcesl Rules and Regulationsl and all applicable California State Laws. <br />Z Signed x .6 ti-e.44a4A.- Title/Company Senior geologist/ WGR Southwest Inc <br />Print Name Caryl Sheehan <br /> <br />March 29 12007 <br /> <br />APR 0 CH/ Aim <br />'.111'1" <br />Grout Inspection By Date <br />Application Accepted By Date Issued <br />Final Inspection By e7 „ , T. 7 ,,V 1 C:19E St e <br /> Area <br />46/61) 7 Date <br />COMMENTS / CONDITIONS <br />ACCOUNTING ONLY: AID* FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # 5 EC'D BY DATE <br />------...„ <br />INVOICE - RMIT / SERV10E-RECIAT% <br />r <br />3°0 Air Pfta5:- 37 (95/?? • , s R# Ott23-02. 0 471- , <br />c-51 i. •7 WC V-WAIVER <br /> <br />C-57 Letter of Author'zation to sign permit <br /> <br />z) _DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILEI ADDRESS: troz4- /€1 Ge /V1 <br />WORK PLAN DATED: 34cC -01- <br />Destruction Inspection By <br />EHD 29-02-001 <br />6/22/04