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600 E. Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />SEP 1 0 2007 <br />San Joaquin County ENVIRONMENT IP! T <br />Environmental Health Department PERMIT/SERV' ;7_ETE <br />MITIGATION <br />UNIT IV <br />HAEMED ORIGINAL <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct end/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 />Assessor. <br />WELL Location _25355 N Hwy 99 <br />Cross Street E caiirn4yrriacity AcampZip 9 5 2 2 0 Parcel/IL / <br />PROPERTY <br />OwnerSar, Joaquin County P. Worxs MO0851810 2, Hal-elton Ave. City Stockton Zip 45205 Phonee_ <br />C-57 COHtfaCtOf GreGg Er 1.1 a rig Address 950 Howe Road City ivirr trip^ Zpj4'33 Lic$4 WD165 Pnone4.2.29B90_, <br />Consultant I Sub Cntr SRI Address 59.1 N. mcDowell. Blvd. City Petaluma Liapac 10-611111, Phone* 70 7 .7 6 6 2 0 0 0 <br /> <br />GIS Coordinates: X 38.2169018 y .121.2687844 Township Range Section <br />WORK TO BE PERFORMED: <br />n(NEW WELL I BORING (CPT, GEOPROBE. HYDROPUNCH, HAND-AUGER, OTHER') <br />gSCYL BOR.NG • C PT4 <br />WELL* <br />*Other <br />COMMENTS <br />()DESTRUCTION (choose type below) <br />13 OVER-BORE. DIAMETER <br />CI PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />TYPE OF WELL <br />0 MONITORING <br />fl EXTRACTION <br />fl VAPOR <br />INSTALLATION TYPE <br />El HOLLOW STEM fl AIR HAMMER/DRIVEN <br />MUD ROTARY <br />CONSTFWCTION SPECIFICATIONS <br />CA. BOREHOLE2 . 2 5 "C MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING. n STEEL C PVC D OTHER: _ <br />DEPTH OF GROUT SEAL 141 TREMIE TYPE TO BE USED: 1:1 AUGERS liDSE <br />a AIR SPARGEJ OZONE gPUSH POINT (GP or CPT)GRDUT SEAL PUMPED: 'Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Cement...az:gut wj <51 pure SOCI.i.UM bentonite <br />0 OTHER: 0 OTHER_ APPROX. BORING DEPTH 140 ' II BOLTED TRAFFIC BOX or D STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: SJC Public Worke Encroachrner,7_ permit application attached. Under review. <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 RKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />red this application and that the work will be done In accordance with San Joaquin <br />gulations, anttag applicable California State Laws. <br />‘') tittecompanCiCel.WAC <br />Lel*A-A e", Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS; 25— 3 5- • <br />WORK PLAN DATED: q9 <br />I hereby certify that I have pre <br />County Ord Rules a d <br />Signed k <br />Print Name <br />Application Accepted By V I: CI-ar ; L (1,4 141- <br />Grout Inspection By it/1hr 14 )neeza Dale/Dz./6 Final Inspection By <br />Destruction inspelon By Date <br />Area <br />ate_ILL—Ar,92 7 <br />Date Issued <br />COMMENTS) CONDITIONS <br />"tdeileeetfteelelleleireeN9W9412116—terw, NW*. 1011.4 Vat .......ftieeleinftelftSMEMIN1 <br />'COUNTING ONLY AIL FACie <br />DATE -')DES FEE INFO AMOUNT REMITTED CHECK <br />3 5(g 9, t7 326 55— L-/21/ 1:2 1' S" 00 5"..2 0 3 '3 <br />C-b7 WC -WAIVER C-57 Letter of Authorization to sign permit E <br />HID 29-02-001 web <br />622/04