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WC -WAIVER <br />EHD 29-02-001 <br />6/22/04 <br />C-57 C-57 Letter of Authorization to sign permit <br />s 60 5 32__LM <br />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 />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 602 North California St. Cross Street Oak City Stockton Zip CA Parcel# 139-165-09 <br />PROPERTY <br />Owner Gary Stallworth Address 602 North California St .City Stockton Zip 95202 Phone# 209-464-1282 <br />C-57 Contractor Gregg Drilling Address 950 Howe Ave City MartinezZip94553 Lie#656407 Phone# 925-313-5800 <br /> <br />Consultant/Sub Cntr Advanced GeoEnvironmental Address 837 Shaw Rd. CityStockton Lic# <br /> <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />Er NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />ig SOIL BORING # CPT -6 (paired) , CPT-7 (paired) , B-4 <br /> <br />a WELL # <br /> <br />U *Other <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />1:1 MONITORING 1:1 HOLLOW STEM DIA. OF BOREHOLE 2 '' a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: _ .....s.., <br />0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: D STEEL g PVC 0 OTHER: <br />['VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 70 ' -80' TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />I:1 AIR SPARGE/ OZONE lif PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FA/ / DEPTH IS 30') <br />ti SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Type II <br />U OTHER: a OTHER APPROX. BORING DEPTH 70 ' -80 ' 0 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 Ordinances, RLesnd Regulations, and all applicable California State Laws. <br />Signed x <br /> <br />Title/Company Staff Scientist/Advanced GeoEnvironmental <br /> <br />Print Name Ally Colavita <br /> <br />Date_o_1/30/08 <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1,0 -7 Gek_A..{),:y-• ' <br />WORK PLAN DATED: <br />SITE <br />MITIGATION <br />UNIT IV <br />El DESTRUCTION (choose type below) <br />['OVER-BORE. DIAMETER <br />fl PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />680227 Phone# 209-467-1006 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />(.1\ Date Issued -Narkisi..".4- <br />Date / it> 4X- Final Inspection By <br />1 3 its- <br />1.A 17(,s, Date Area J O t <br />Date <br />liV>1.AAA 0.1", <br />COMMENTS! CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # 5 EC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />3 5-o I <br />;5-0 <br />Ii S-ct .o 0 <br />If zety,0 0 -7-69 ctf Gt-, 1/31 /6 % SR# 5-32_61