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-.-San Joaquin County <br /> o Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd 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 602 North California St. Assessors <br /> Cross Street Oak City Stockton Zip CA Parcel# 139-165-09 <br /> PROPERTY <br /> Owner Gary Stallworth Address 602 North California St.City Stockton Zip 95202 Phone# 209-464-1282 <br /> C-57 Contractor Gregg Drilling Address 950 Howe Ave City MartinezZip94553 Lic#656407 Phone# 925-313-5800 <br /> Consultant/Sub Cntr Advanced GeoEnvironm ntal 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 /> t3 NEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 4 SOIL BORING# CPT-6(paired),CPT-7(paired),B-4 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 70' -80' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE g 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 701 -80' 0 BOLTED 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 s nd Regulations) and all applicable California State Laws. <br /> Signed x_ TSZ Title/Company Staff Scientist/Advanced GeoEnvironmental <br /> Print Name Ally Colavita Date <br /> DEPARTMENT USE ONLY . k W• <br /> SITE MAP IN UNIT IV FILE, ADDRESS: G,0 2 ra ttif �1AA C- + y <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued o Area i <br /> Grout Inspection By 1 ���nnn e,� Date z 6 O g Final Inspection By Date 6 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 5EC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3sol J3 �t•oC' � 6�15`f (,(5 t/3��oS SR# �7, 26� <br /> so 3 ff zaY.no <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />