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hi [I Y/I�flU <br />SAN JOAQUIN COUNTY OPR 0 6 2009 <br />ENVIRONMENTAL HEALTH DEPARTNiffiMMONMENI HEAL -SITE <br />600 East Main Street, Stockton, CA 95202-30ffRMIT/SERVICES <br />�srk ,Jr' Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.org/ehd MITIGATION <br />�g F.o. ?r 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 />Well Location 3330 N El Dorado St. Cf055 Street East Alpine Avenue City Stockton zip 95209 Assessors <br />Parcel# 115-15-301 <br />Property <br />Owner Jose L. Perez Address 3330 N E1 Dorado Street City Stockton Zjp 95204 Phone# <br />3632 Onnec Circle C57-717510 <br />C-57 Cont2ctOtCascade Drilling, Inc Addre55 City Rancho Cordova Lic# Phone 916-638-1169 <br />Consultant/Sub Cntr ETIC Engineering Address 2285 Morello Ave. City Pleasant HillLiC# 624022 phone 925-602-4710 <br />GIS Coordinates: X , Y , Township 02N Range 06E Section 34 <br />WORK TO BE PERFORMED: <br />® NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ SOIL BORING# ❑ OVER -BORE DIAMETER <br />® WELL# 2 (14W8 and DW4) ❑ PRESSURE GROUT <br />❑'OTHER GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />® MONITORING 1a HOLLOW STEM DIA. OF BOREHOLE 8" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 2 s <br />❑ EXTRACTION ❑ AIR HAMMER/DRIVEN CASINGTHICKNESS Sch. 40 TYPE OF CASING: ❑ STEEL E2 PVC ❑ OTHER <br />❑ VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL 71' , 21' TREMIE TYPE TO BE USED ® AUGERS [a HOSE <br />❑ AIR SPARGE(OZONE ❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ❑ Yes ® No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS Neat cement <br />❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 85' , 45' ® BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />CONDUCTOR CASING PROPOSED Yee (DW4) (it YES, list specrostions in comment section) <br />COMMENTS: B-5/8" O.D. steel conductor casino from surface to 50' <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />I harsh c i that I have rep red this applic��ati33nn--aannd that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulatio S, nd appli le C "demtSlaws. 1` //11 ,p T 1 <br />Signed Title/Company ` .l. SCA.r 1� Q Vim 11\It r t l n� <br />Print Name '�:)Cx I k 4!::Z�h Q Q _[�,r�l�\/Q nmo I X11 I Clq <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: J ti Cbes!6t.`. — ELL,.) QP M_ . <br />WORK PLAN DATED:_ _ -_ f ,r1.5.,,,�(K„ 2.Ob SC <br />APPLICATION ACCEPTED BY 1.O a �---_ _ DATE ISSUED 11.1 PL I d") AREA <br />GROUT INSPECTION BY tk'>,� FINAL INSPECTION BY DATE Edi <br />DESTRUCTION INSPECTION BY <br />COMME NTSICONDITI ONS: <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />PERMIT/SERVICE# <br />INVOICE <br />zotol <br />4 ".oa <br />501 ,40 <br />Y 9 oS <br />SR# 5618'0 <br />57 _ _ WC <br />-WAIVER C57 LETTER OF AUTHORIZATION <br />TO SIGN PERMIT FNCROACHMFNT <br />nor. <br />EHD 2401 11/5/07 (WEB) WELL PERMIT APP <br />