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OSan Joaquin County In <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95244R — 4 2008 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgovictbd. 011 HEALTH UNIT IV <br />Well Permit Application • ,F'R.V!Cr'' <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 521 East Oak Street Cross Street California City Stockton Zip 95202 Parcel# 139-165-08 <br />PROPERTY <br />Owner Carlos Rodriguez Address 128 Wilshire Court City Danville 494526 Phone# 510-885-1347 <br />C-57 Contractor Mitchell Drilling Address 7900 Myrtle Ave City Eureka Zip95503 Lic# 672617 Phone# 707-444-9040 <br />Consultant/Sub Cntr Advanced GeoEnvironmental Address 837 Shaw Rd. City Stockton Lic# 680227 Phone# 209-467-1006 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />ff NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />a SOIL BORING # fl OVER-BORE. DIAMETER <br />tl WELL # MW-b a PRESSURE GROUT <br />a *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />fj MONITORING if HOLLOW STEM DIA. OF BOREHOLE 8" a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: _2" <br />0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS SCD 40 TYPE OF CASING: a STEEL 11 PVC a OTHER: <br />a VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 56 TREMIE TYPE TO BE USED: II AUGERS a HOSE <br />a AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE -FA/ / DEPTH IS 30') <br />0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Portland Type II <br />1:1 OTHER: a OTHER APPROX. BORING DEPTH 70' [kBOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED NA (if YES, list specifications in comment section) <br />COMMENTS: ..--t-- <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 Ordinances R es nd Regulations, and all applicable California State Laws. <br />Signed x <br /> <br />Title/Company Staff Scientist/Advanced GeoEnvironmental <br />Date 03/03/08 <br /> <br />Print Name Ally Colavita <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: t,c5 7 Coa"..fp-1 <br />WORK PLAN DATED: <br />Application Accepted By NrtAA.A.rt <br />Grout Inspection By Date Final Inspection By Date qi <br />Date Issued ("0-- Area <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: <br />Date <br />ACCOUNTING ONLY: AID# FAC# C 6'Ro a <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # 5EC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />S R# <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit V Encroachment doc <br /> <br />EHD 29-02-001 <br />6/22/04