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Application Accepted B <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued <br />Final Inspection By <br />'Ign 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 /> <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> <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 Road Cross Street Lincoln City Stockton Zip 95206 Parcel# 165-040-04 <br />PROPERTY <br />Owner GAUT GREGORY A & PAULETTE Address 18120 ARRIGONE WAY City LINDEN Zip 95236 Phone# (209)466-4601 <br />C-57 Contractor Gregg Drill i ng Address 950 Howe Ave. <br /> <br />City Martinez Zip 94553Licg 656407 Phone# (925)313-5800 <br /> <br />Consultant / Sub Cntr Advanced Ge °Environment al Address Fl City Stockton Lic# 680277 Phone# (209)467-1006 <br />GIS Coordinates: X <br /> <br /> , 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 />a SOIL BORING # CPT-2 a OVER-BORE. DIAMETER <br />a WELL # U PRESSURE GROUT <br />U *Other GROUT SPECIFICATIONS <br />COMMENTS. <br />0 AIR SPARGE/ OZONE fl PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FA/ / DEPTH IS 30') <br />13 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Type Tica p.it 1 aan-ri, <br />O OTHER: a OTHER APPROX. BORING DEPTH 35 -.1--- `4)7 Ili BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED NO (if YES, list specifications in comment section) <br />BORING LOCATION INCLUDES THREE ADDITIONAL ADJACENT BORINGS FOR THE COLLECTION OF GRAB GROUND WATER SAMPLES; <br />ON-SITE INVESTIGATION FOR COMFORT AIR. <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 Rules ard Regulationsi and all applicable California State Laws IL_» _ <br />11111LAL <br />Signed x <br /> <br />Title/Company Staff Scientist <br />Date 08/20/08 AUG 2 0 2008 <br /> <br />Print Name A enn rn1 avi t-A <br /> <br />DEPARTMENT USE ONLY ENVIRONMENT HEALTH <br /> <br />SITE MAP IN UNIT IV FILE, ADDRESS: I 407 Tt) rn io;ke Roao( PERMITISFRVicPs <br />WORK PLAN DATED: June 5-1 2. 00 8 <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />D MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2 i, a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: NA ) <br />O EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: a STEEL 0 PVC I] OTHER: '1-3 <br />0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL SFC-TD TREMIE TYPE TO BE USED: B AUGERS 0 HOSE — <br />-R <br />i 22/ 0 8 Area j 459 <br />VAhr i a M te2ti71e7 Date 9/ 21 0 8 <br />COMMENTS / CONDMONS: Advancement o-F C PT- 2 cuts ;-}e +6 iro a-i-e I¼.i )3Orfksj . <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # 5 EC'D BY DATE INVOICE P _.._ <br />35 -6 / <br />3503 <br />a 9. 0 0 <br />315.00 <br />ott 46 4 , 00 3 2+7 it 9 /2 2 8 SR# 0056-200 <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />EHD 29-02-001 <br />6/22/04