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"aDr,y �o man Joaquin County <br /> FILE COPY <br /> y1 K Environmental. Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> c P (209)468-3449 Fax, (209)468-3433 Web: www.sjgov.org/ehd MITIGATION <br /> UNIT IV <br /> i ~F�RNP Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C <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 1717 South Center Street Cross Street W 3rd St. qty StocktonZf 95206 Assessors <br /> PROPERTY - P Parcel# 165-072-28 <br /> Owner_ Ci tv of Stockton Address 22 E. Weber Ave. <br /> City Stoc ktonZip 95202 Phone# 209-937=8366 <br /> C-57Contractor frcg,g Drilling Address 950. Howe Road - C57485165 <br /> City Martinez Zip945 33 Lic# Phone#925-313-5800 <br /> Consultant l,Sub Cntr PSC Address 210 W. Sand Bank Rd Columbia { <br /> City Lie# Phone# 618-281-1543 <br /> GIS Coordinates:X _ Y ,Townsfii 1 N - - -+ <br /> P Range 6E. Section 14. <br /> WORK TO BE PERFORMED -� _ y <br /> Q NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER;OTHER-) Q DESTRUCTION <br /> Q SOIL BORING# (choose type below) <br /> WELL#..MW-2A - _ - 0OVER-BORE. DIAMETER <br /> Q'Other - Q PRESSURE GROUT <br /> COMMENTS: <br /> GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS' <br /> L MONITORING <br /> I HOLLOW STEM DIA.OFn <br /> BOREHOLE 8 Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS Sch. 40 < TYPE OF CASING: <br /> Q VAPOR � - Q STEEL I PVC Q OTHER: <br /> Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS I, Q HOSE <br /> Q AIR SPARGFJ OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: IYes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS Neat cement <br /> Q OTHER:_0 OTHER APPROX.BORING DEPTH 45-59 <br /> I BOLTED TRAFFIC BOX or Q STOVEPIPE <br /> CONDUCTOR CASING PROPOSED one <br /> (if YES,list specifications in comment section) <br /> ayi <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 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, eses and Regulations, and all applicable California State Laws. <br /> f , ,� <br /> Signed f Title/Company Protect Mana er <br /> PrintName Paul Anderson -1 . . Date 1j14Z c &r <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: l f GOA 3 ,. <br /> WORK PLAN DATED: / <br /> Application Accepted By Date Issued Areas D(O <br /> Grout Inspection Date '� Final Inspection By ate- S <br /> Destruction Inspection By Date ..�..��„ <br /> COMMENTS/CONDITIONS: <br /> i <br /> hA OUNTING'ONLY: AID# FAC# - <br /> ODES FEEINFO AMOUNTREMITTED CHECK#• RE�C+',DDBB.Y DATE PERMIT/SERVICE REQUEST# .INVOICE <br /> 50 1 I�O ��'/rU c.r-t.(, 2) SR# D <br /> C-57 WC=WAIVER_ C-57 Leiter of Authorization to sign permit_Encroachment doc � <br /> EHD 29-02-001 WEB - <br /> 9111/2007Aue o0. 6W <br />