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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 521 East Oak Street Cross Street California City Stockton Zip CA Parcel# 139-165-08 <br />PROPERTY <br />Owner Carlos Rodriquez Address 128 Wilshire court City Danville Zip 94526 Phone# 510-885-1347 <br />C-57 Contractor Gregg Drilling Address 950 Howe Ave City Martinez Zip94553 Lio#656407 Phone# 925-313-5800 <br />Consultant/Sub Cntr Advanced GeoEnvironmental Address 837 Shaw Rd. CityStockton Lic# 680227 Phone# 209-467-1006 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />g NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />11 SOIL BORING #fpT-8 (paired). 5-5 a OVER-BORE. DIAMETER a WELL # a PRESSURE GROUT <br />a *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />CONSTRUCTION SPECIFICATIONS <br />a MONITORING a HOLLOW STEM DIA. OF BOREHOLE 2 " a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />a EXTRACTION fl AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br />a VAPOR OMUDROTARY DEPTH OF GROUT SEAL 70' -80' TREMIE TYPE TO BE USED: g AUGERS [I HOSE <br />El AIR SPARGE/ OZONE 11 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: [i Yes a No (NOTE: MAXIMUM FREE-FA/ / DEPTH IS 30') <br />fiSOIL BORING a HAND AUGER GROUT SPECIFICATIONS Portland Type II <br />a OTHER: U OTHER APPROX. BORING DEPTH 70 1 -80 ' a 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 Ordina ces Ru es and Regulations, and all applicable California State Laws. <br />Signed x <br /> <br />Title/Company Staff Scientist/Advanced GeoEnvironmental <br />Print Name Ally Colavita <br /> <br />Date 1/3 n /0 8 <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: c“:70 ? r,eN, AA„V./1 c4- - <br />WORK PLAN DATED: 1 -Llt 2-16 '7- <br />SITE <br />MITIGATION <br />UNIT IV <br />Application Accepted By kik")..4A.,,e, <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: <br />Date Issued 1/3 Ito cK <br />Date Z (40 3 Final Inspection By Date Zig /0 <br />Date <br />Area g7 r <br />ACCOUNTING ONLY: AID# FAC# (........_____ 3Roo6336 ) <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # 5 EC'D BY DATE PERMITThrRVICEIUEST # INVOICE <br />.5 5-01 <br />2 s 0 17 <br />11 45-9 ,00 <br />0 z ell If , p 0 7-69 5-t-t tik k I 31 les SR# <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