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�0 ,.San Joaquin County -.W <br /> W z� 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 521 East Oak Street Assessors <br /> Cross Street California City Stockton Zip CAParcel# 139-165-08 <br /> PROPERTY <br /> Owner Carlos Rodriquez Address 128 Wilshire Court City Danvj e Zip 94526 Phone# 510-885-1347 <br /> C-57 Contractor_Gregg Drilling Address 950 Howe Ave City Martinez Zip94553 Lic#656407 Phone# 925-313-5800 <br /> Consultant/Sub CntrAdvanced GeoEnvironm ntalAddress 837 Shaw Rd. CityStockton Lie# 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 /> SOIL BORING#CPT-8(paired) B-5 0 OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> *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 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: ff 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 /> 1]SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Type II <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 7n' -An' 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 Ordi Ru es and Regulations) and all applicable California State Laws. <br /> Signed x_ Title/Company Staff Scientist/Advanced GeoEnvironmental <br /> Print Name Ally Colavita Date <br /> DEPARTMENT USE ONLY FILE <br /> SITE MAP IN UNIT IV FILE, ADDRESS: x,07 ra., ACC/)1AAC- S I <br /> WORK PLAN DATED: IZ 1 12. to -�- <br /> T <br /> Application Accepted By Date Issued 1 13 1 In Sc Area <br /> Grout Inspection By LA�,�2 Date Z Os 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 /> 343-vl �q•oo 26�5y SR# S3z 6 FS <br /> ozi �( zgK•o� <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit i Encroachment dockl' <br /> EHD 29-02-001 <br /> 6/22/04 <br />