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San Joaquin County <br /> Envi>tmental Health Department (_�RECE TE- <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 NOV .MR7IGATION <br /> (209)468-3449 Fax: (209).468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application ENVIRONME -WEALIH — <br /> PERM/SERVICES <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 /> Assessors <br /> WELL Location 16500 Clifton Road Cross Street Tracy Blvd City Stockton Zip 95206 parcey1189-040-11 <br /> PROPERTY <br /> Owner Sandi Sarale Address P.O. Box 6066 City-Stockton Zip95206 Phone#(209)943-2079 <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road CityMartinez Zip94553 Li485165 Phone# (925)313-5800 <br /> Consultant/Sub Cntf Advanced GPoEnvironmental Address A'47 .Shaw AA City Stockton LIC# 680227 Phone# 12091 467-1006 <br /> GIS Coordinates:X �7 cIbL <br /> •� � 9009 -lzl'S�zZL .9 Township Range Section <br /> WORK TO BE PERFORMED: <br /> $NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER*) B DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# MW-10 -11 0 PRESSURE GROUT <br /> ©*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> JYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING B HOLLOW STEM DIA,OF BOREHOLE 8° B MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA: 2" <br /> B EXTRACTION B AIR HAMMERIDRIVEN CASING THICKNESS schdl 40 TYPE OF CASING: B STEEL IfPVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 2'/x8' TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> B AIR SPARGE/OZONE B PUSH POINT(GP or CPT)GROUT SEAL PUMPED: B Yes B{No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> B SOIL BORING B HAND AUGER GROUT SPECIFICATIONS Port land <br /> 0 OTHER:_B OTHER APPROX.BORING DEPTH 20'/25' ]f BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:Soil samples for monitoring well installation <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 Or ' ances, R a Regulations, and all applicable California State Laws. <br /> Signed x Title/Company Staff Scientist/AGE <br /> Print Name Gavin D. McCreary Date 5 November 2007 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: chi ZCx9 Gi�'r1 l �v�isf X07 <br /> Application Accepted By A4,vl Date Issued /W'o- �LF oZ6U 7 Area 1S <br /> Grout Inspection By �,(� G�,L Date ///9� Final Inspection By Date F <br /> Destruction Inspection By Da e <br /> COMMENTS 1 CONDITIONS: <br /> FACCOUNTING ONLY: AID# FAC# <br /> FEE INFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> X28 oD $3as. 2� Yq5 CN1"+c 02 tibu "o SR#,Qo -7 <br /> C-57 WC -WA1VER C-57 letter of Authorization to sign permit Encroachment doc <br /> EID 29-02-001 - <br /> 6/22/04 <br />