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32 Aqulk �a ran Joaquin County <br /> . <br /> 0304 Environmental Health Department SITE East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> 'ZO io (209)468-3449 Fax: (209)468-3433 Web: www.sigov.org/ehd <br /> t ,�� Well Permit Application UNIT IV <br /> ly i � NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicat{ERMIIAM 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 /> jjG <br /> WELL Location E.Charter Way Grant Street 95207 Assessors 167-181 fd <br /> Cross Street City Stockton Zip Parcel# <br /> PROPERTY <br /> Owner Frank Kozlik Trust Address PO Box 255708 City Sacramento <br /> .-Z095865 Phone# <br /> C-57 Contractor V&W Drilling Address 3806 Duck Creek DriveStockton <br /> City Zip95215 Lic#720904 phone#(209)469-7700 <br /> Consultant/Sub Cntr Geological Technics Inc Address 1172 Kansas Avenue City Mndecto Lic#--n/a Phone# (209)522-4119 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: MW-5,6, 106, 108, 109, 110,209,210 <br /> g NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) ®DESTRUCTION (choose type below) <br /> 0 SOIL BORING# HOVER-BORE. DIAMETER R" <br /> WELL# <br /> a*Other PRESSURE GROUT <br /> GROUT SPECIFICATIONS �(VWJ—' <br /> COMMENTS: See Work Plan dated 11 2q OIJ4�<ar%\k +L to Dfw55 /rro 1 �6, Lo6t la$LLJ�t�14v, <br /> •7 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL O PVC Q OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS Q HOSE e0 <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FgEE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS_ <br /> OTHER: 0 OTHER APPROX.BORING DEPTH o BOLTED TRAFFIC BOX or a STOVE PIPE <br /> COMMENTS: See Work Plan dated CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <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, Rule*,and g tions, and all applicable California State Laws.� <br /> Signed x Mb <br /> /�� <br /> Print Name E l(1 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 5" Zf't 'LU l c7 <br /> Application Accepted By 10�6."tr"4�' Date Issued Z l Area <br /> Grout Inspection By .Date Final Inspection By Date 4 `L <br /> Destruction Inspection By Date 4 L;—,> <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> LPECODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> dt.v,3oa.� a > t;'7,Z VC 3lrs)ca SRO �'ot <br /> C-57,/- WC -WAIVER_ C-57 Letter of Authorization to sign permij/' Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br /> i <br />