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FD- <br /> 'Paul. _San Joaquin County � � <br /> 2'p c�z <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 9520V! ' MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgovigt 'f'�� I'l ei�_�1� Ci -ALTH UNIT IV <br /> q</fioR% 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 95202 Parcel# 139-165-08 <br /> PROPERTY <br /> Owner Carlos Rodriguez Address 128 Wilshire Court City Danville Zip94526 Phone# 510-885-1347 <br /> C-57 Contractor Mitchell Drilling Address 7900 Myrtle Ave City Eureka Zip95503 Lic#672617 Phone# 707-444-9040 <br /> Consultant/Sub CntrAdvanced GeoEnvironmentalAddress 837 Shaw Rd. CltyStockton LIC# 680227 Phone# 209-467-1006 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 4]WELL# MW-10 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 13 MONITORING D:HOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_2 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCD 40 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 56' TREMIE TYPE TO BE USED: EFAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FA// DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Type II <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 70' [kBOLTED TRAFFIC BOX or 0 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 Ordinances R es nd Regulations, and all applicable California State Laws. <br /> Signed x — Title/Company Staff Scientist/Advanced GeoEnvironmental <br /> Print Name Ally Colavita Date 03/03/08 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 6 Z 1A �A�S FILF ROY <br /> WORK PLAN DATED: <br /> Application Accepted By L[lrin I-C11•— Date Issued s /C, Area <br /> Grout Inspection By Date Final Inspection By [ Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 5 EC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ('dSCP Z �oSd /�/n� SR# JC 3S3b <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit ✓Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />