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- !L SITE k / <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 20MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd Hrt UNIT V <br />a V <br />an Joaquin County <br />Environmental Health Department <br />7/sc.-RI/I & <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 1607 Turnpike Rd. Cross Street Lincoln St. City Stockton Zip 95206 Parcel# 165-040-04 <br />Well Permit Application <br />PROPERTY <br />Owner Greg Gaut <br />C-57 Contractor All Well <br /> Address 18120 Arrigone Way City Linden Zip 95236 Phone# 209-466-4601 <br />Mi 7111./07 <br />City PlacervilleZjp 95667 Lio# 84859 Phone# 530-644-1122 Abandonment Address 3809 Pleasant Valley Rd. <br />Consultant / Sub CntrAd vanred GeoEnvironmeatal Address 837 Shaw Rd. CitYStockton Lic# 680227 Phone# 209-467-1006_ <br />GIS Coordinates: X , 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 />U SOIL BORING # a OVER-BORE. DIAMETER <br />WELL # EX-2 a PRESSURE GROUT <br />U *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />O MONITORING 0CHOLLOW STEM DIA. OF BOREHOLE 12 a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 4 " <br />Ef EXTRACTION <br /> U AIR HAMMER/DRIVEN CASING THICKNESS SCHD 40 TYPE OF CASING: fl STEEL la PVC a OTHER: <br />O VAPOR U MUD ROTARY DEPTH OF GROUT SEAL 11 ' TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />O AIR SPARGE/ OZONE U PUSH POINT (GP or CPT)GROUT SEAL PUMPED: U Yes U No (NOTE: MAXIMUM FREE-FA/ / DEPTH IS 30') <br />U SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Type II Portland <br />U OTHER: U OTHER APPROX. BORING DEPTH 35' a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED na (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 Ordinan and egulationsi and all applicable California State Laws. <br />Signed x Title/Company Vice President <br />Print Name Robert Marty <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1 1,0 7 Turn k. <br />WORK WORK PLAN DATED: Ju I y 10 .2 00 7 <br />Date 07 /10/07 <br />Application Accepted yy y M e../14 <br />Grout Inspection By ViC.-1-6-r; et etar 471-e. Date • / 0'7 <br />Destruction Inspection By Date <br /><AA I (.1 1 2. 0 7 Area i45/ <br />Final Inspection By V; eA-er dta I +4 cfate - 14)-01 <br />Date Issued <br />COMMENTS / CONDITIONS: Installal-:oxi 6c- eX --1- ra icie, AI,i )1 EX -2 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # SEC'D BY DATE PER CE REQI INVOICE <br />3.50 1 <br />3 5- 0 3 <br />„k el <br />$ -2 35. 3 '7 4- . 0 .5.-9 G I Le-hi 7/14107 SR# 00.5-1 2 ,7 9 <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit ent_dat----- <br /> <br />EHD29-02-001 <br />6/22/04