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NEDEnvironsmental <br /> an Joaquin County <br /> z� Health Department SITE <br /> w 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (VlEtNT <br /> 204209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> C, HEALTH Well Permit Application <br /> PERMIT/SERVICE�ON-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. L+'.9 t2o14J <br /> Grant Street95207 Assessors .--oT <br /> WELL Location Corner of Grant&Charter Cross Street City Stockton Zip Parcel# <br /> PROPERTY <br /> Owner City of Stockton Address 425 N EI Dorado City Stockton Zip 95202 Phone# <br /> V&W Drilling 3806 Duck Creek Drive Stockton 95215 720904 (209)469-7700 <br /> C-57 Contractor Address City Zip Lic# Phone# <br /> Consultant/Sub Cntr Geological Technics Inc Address 1172 Kansas Avenue City Modesto Lic# n1a Phone# (209)522-4119 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: MW-111 <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) H DESTRUCTION (choose type below) <br /> Q SOIL BORING# OVER-BORE. DIAMETER }>; <br /> WELL# []PRESSURE GROUT <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: See Work Plan dated 1129 I10 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING []HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:------ <br /> EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS []HOSE <br /> AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING Il HAND AUGER GROUT SPECIFICATIONS 1N � �pvryle-w T- <br /> a OTHER: []OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: See Work Plan dated <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules a d Regulatio s, and all applicable California State Laws. <br /> Signed x n /Company � �� T <br /> Print Name ( �nlx� ]� _ Date -2 la 1 D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: \AC <br /> WORK PLAN DATED: -r'V(Z> <br /> Application Accepted By � Date Issued Area <br /> Grout Inspection By Date Final Inspection By '✓1 • Date A ('t4'[G) <br /> Destruction Inspection By Date a Frig C� <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35,° -gof's aZ,o7 C' — tzzLtJ SR# <br /> gSo , 34>-'7•-) `3 3 <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 />