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in Joaquin County <br />Environmental Health Department <br /> <br />SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />UNIT IV <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 1601 Turnpike Road Cross Street Lincoln City Stockton Zip 95206 Parcel# 165-040-13 <br />PROPERTY <br />Owner LOPEZ NEREIDA P Address PO BOX 6569 City STOCKTON Zip 95206 Phone# (760)455-3239 <br />C-57 Contractor Gregg Drilling Address 950 Howe Ave. City Marts ne7 Zip 94553Lic# 656407 Phone# (925)313-5800 <br />Consultant / Sub Cntr Advanced GeoEnvironmental Address f417 qllaw PH City Stockton Lic# 690797 Phone# (2091467-1006 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />a NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />1:1 SOIL BORING # CPT-1,B-4,B-6,B-7 <br />WELL # <br />O *Other <br />0 DESTRUCTION (choose type below) <br />OVER-BORE. DIAMETER <br />a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS: <br /> <br />TYPE OF WELL <br /> <br />INSTALLATION TYPE <br /> <br />CONSTRUCTION SPECIFICATIONS <br />MONITORING <br /> <br />HOLLOW STEM <br /> <br />DIA. OF BOREHOLE 2 " 0 MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: NA <br />fl EXTRACTION <br /> <br />AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: U STEEL U PVC U OTHER: <br />VAPOR <br /> <br />MUD ROTARY <br /> <br />DEPTH OF GROUT SEAL SFC-TD TREMIE TYPE TO BE USED: fj AUGERS U HOSE <br />AIR SPARGE/ OZONE fl PUSH POINT (GP or CPT)GROUT SEAL PUMPED: U Yes <br />No (NOTE: MAXIMUM FREE-FA/ / DEPTH IS 30') <br />COMMENTS: <br />GROUT SPECIFICATIONS Type TT Portland <br />APPROX. BORING DEPTH 70-180 ' 0 BOLTED TRAFFIC BOX or U STOVEPIPE <br />CONDUCTOR CASING PROPOSED NO (if YES, list specifications in comment section) <br />EACH BORING LOCATION IS A PAIRED BORING; ON-SITE INVESTIGATION FOR LOPEZ PROPERTY. <br />a SOIL BORING <br />OTHER: <br />HAND AUGER <br />OTHER <br /> <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 Ordi nces an Regulations, and all applicable California State Laws. CE VP 9) ,J <br />Signed x <br /> <br />Title/Company Staff Scientist <br />Date 08/20/08 Al Ir. 9, ei 2008 <br /> <br />Print Name All eon rn1Rvi t a <br /> <br />ENVIRONMENT HEALTH <br />SITE MAP IN UNIT IV FILE, ADDRESS: 16,o1 I urn joik odd PFRAil(TISERVICFS <br />WORK PLAN DATED: I\,/\ Ot y ) 0 0 <br />Application Accepted By V i CA-6 L A/1 c C.6 1411 P Date Issued <br />Grout Inspection By \I i et:1-D r-14.indir'4ngt7 Date 5 4 - 3-0 9 Final Inspection By 4.01.41k Date 9-s---0g <br />Destruction Inspection By Date <br />COMMENTS! CONDITIONS: Av.i n erne rif n CPT -1 B-4 t-id B-'7 <br /> <br />DEPARTMENT USE ONLY <br />Au)lys f.22) 2-00 8 Area 145'? <br />ACCOUNTING ONLY: AID# <br />/ <br />FAC# I <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # 5 EC'D BY DATE PE T # INVOICE <br />?so, <br />3 o 3 <br />e 8 9. co <br />IP 3 15. oo <br />li4o4-. 0 0 3245 W.)? 81.2V 8 sR# 005-5-20q2 <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br /> <br />ncroachment doc <br /> <br />EHD 29-02-001 <br />6/22/04