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J <br />• „ L Title/Company Staff Scientist <br />Date 08/20/08 <br />DEPARTMENT USE ONLY <br />Signed x <br />Print Name A1on rnl avi 1- a <br />AUG 2 0 2008 <br />'an 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.ORIGINAL UNIT IV <br />Well Permit Application <br />SITE <br />MITIGATION <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 1607 Turnpike Road Cross Street Lincoln City Stockton Zip 95206 Parcel# 165-040-04 <br />PROPERTY <br />Owner GAUT GREGORY A & PAULETTE Address 18120 ARRTGONF, WAY City LINDEN Zip 95236 Phone# (209)466-4601 <br />C-57 Contractor Gregg Drilling Address 950 Howe Ave. <br /> <br />City Martinez Zip 94553Lic# 656407 Phone# (925)313-5800 <br /> <br />Consultant / Sub Cntr Advanced GeoEnvironment al Address R17 qlnAw Rd City Stockton Liet R 0227 Phone# (209)467-1006 <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />B NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 8 SOIL BORING # 5 -5 <br />a VVELL # a *Other <br />0 DESTRUCTION (choose type below) <br />a OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS. <br /> <br />INSTALLATION TYPE <br /> <br />CONSTRUCTION SPECIFICATIONS <br />U HOLLOW STEM DIA. OF BOREHOLE 2 " a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: NA <br />AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: OSTEEL a PVC OTHER: <br />O MUD ROTARY DEPTH OF GROUT SEAL SFC-TD TREMIE TYPE TO BE USED: 13 AUGERS a HOSE <br />fi PUSH POINT (GP or CPT)GROUT SEAL PUMPED: fl Yes a No (NOTE: MAXIMUM FREE-FA/ / DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS Type TT Pori- 1 anri <br />OTHER APPROX. BORING DEPTH 70-12 0 ' a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED NO (if YES, list specifications in comment section) <br />COMMENTS: BORING LOCATION IS A PAIRED BORING; OFF-SITE INVESTIGATION FOR LOPEZ PROPERTY. <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 an egulationsi a nd all applicable California State Laws. <br />, <br />TYPE OF WELL <br />a MONITORING <br />o EXTRACTION <br />O VAPOR <br />13 AIR SPARGE/ OZONE <br />B SOIL BORING <br />O OTHER: <br />SITE MAP IN UNIT IV FILE, ADDRESS: I 6, 0 1 TUrnp;ke -Road <br />WORK PLAN DATED: M cay .2 t aao <br />Application Accepted By V1 CA*Or ;it L. ivle.(cir+n e Date Issued fklejal/St 22.) -2o n Area )45-GI <br />ENVRONMENI HEALTH <br />FIK MI /Z)LH. \110-±) <br />Grout Inspection By 1* ; CAW 4 1. .0 I 161-in, Date q-5— Final Inspection By :4902edfrivro.7 Date '9—S" 8 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: Ad Va t1C evvte4± CfS 13 -s- a4-5:+e Lt.+ 11,0 17 Torn ;ke Rol <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # 5EC'D BY DATE PERMIT / SERVICE ES INVOICE <br />3301 <br />350 3 <br />* <br />"." 3 i56 1'4 04- 0 a 324-4 `1/171 912 pg SR# <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permi <br /> <br />ncracic-hinent doc <br /> <br />EHD 29-02-001 <br />6/22/04