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San Joaquin County RECEIPPL {J <br /> <br />Environmental Health Department ITE <br /> <br />600 East Main Street, Stockton, CA 95202-3029 JUN 0 4 2MTIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />ENVIRONMENT HEAL! H Well Permit Application PERMIT/SERVICES <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 />Wilson Way & Assessors <br />WELL Location 101 S. Wilson Way Market St. Cross Street City Stockton zip 95205 Parcel* 051-253-008 <br />PROPERTY <br />Owner Paul Surinder Address 2741 Otto Drive City Stockton zip 95209 Ph one* 209-462-7327 <br />C-57 Contractor Gregg Drilling Address 950 Howe Rd . City Martinez zip 94553 Lico 485165 Phone* 925-313-5800 <br />Consultant / Sub Cntr A.G. E . Address 837 Shaw Rd . City Stockton Lic# Phone* 209-467-1006 <br />GIS Coordinates: X Y , Township Range Section <br />WORK TO BE PERFORMED: <br />)(MEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />*SOIL BORING B-7, 5-8 & 5-9 ['OVER-BORE. DIAMETER <br />a WELL* a PRESSURE GROUT <br />a *Other GROUT SPECIFICATIONS <br />COMMENTS: SEE WORK PLAN DATED 10 JANUARY 2008 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />II U MONITORING I] HOLLOW STEM DIA. OF BOREHOLE <br />Q <br />- a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC I] OTHER: <br />U VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 40 ' TREMIE TYPE TO BE USED: trAUGERS a HOSE <br />BAIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: tr(es a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />>TSOIL BORING a HAND AUGER GROUT SPECIFICATIONS PORTLAND TYPE II GROUT <br />O OTHER: 0 OTHER APPROX. BORING DEPTH 40 ' g BOLTED TRAFFIC BOX or g STOVE PIPE <br />CONDUCTOR CASING PROPOSED NO (if YES, list specifications in comment section) <br />COMMENTS: SEE EHD APPROVAL LETTER DATED 21 MARCH 2008 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />Title/Company PROJECT GEOLOGIST/A . G. E . <br />Print Name TIMOT J. CUELLAR Date 06/0 3/01 <br />DEPARTMENT USE ONLY <br />LO !L 5 . LJ . Is o <br />Application Accepted By /17i;e1 seyo Date Issued / 7 (.7" ne 20V if Area /445 3 <br />Grout Inspection By /WA/ Date 7/4, 1 7///aFinal Inspection By AA Date 7/11/4 E" <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS. <br />ACCOUNTING ONLY: AID* FAG* <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PER EST # INVOICE <br />35 0 1 <br />3D 3 <br />i V, <br />t 29 4/ li 383-' 2744 2. Ciuri_ GliVorgrt# 00 54571 ' <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit —".1.11111111.1111IMPSIOP <br /> <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, Rules and Regulations, and all applicable California State Laws. <br />Signed x <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />EHD 29-02-001 WEB <br />9/11/2007