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D � � <br /> �. +N. San Joa uin County <br /> 9 tY <br /> Environmental Health Department NOV 0 2 2007 SITE <br /> { 304 East Weber Avenue, 3rd Floor, Stockton,CA "�$r MITIGATION <br /> • (209)468-3449 Fax: (209)468-3433 Web: www.sjgay. A9ENT EAI' UNIT IV <br /> MIT/SERVICES <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 /> Assessors <br /> WELL Location 16500 Clifton Road Cross StreetTracy Blvd City Stockton Zip 95206 Parcel#189-040-11 <br /> PROPERTY Stockton 95206 <br /> OwnerSandi Sarale AddressP•O. Box 6066 City Zip Phone# (209)943-2079 <br /> C-57 ContractorGregg Drilling Address 950 Howe Road Cih,Martinez Zip94553 Lic#485165 Phone# (925) 313-5800 <br /> Advanced GeoEnvironmental 837 Shaw Rd Stockton (209)467-1006 <br /> Consultant I Sub Cntr Address City Lic#680227 Phone# <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUN CH,HAND-AUGER, HER') p DESTRUCTION (choose type below) <br /> n SOIL BORING# OVER-BORE. DIAMETER <br /> [rWELL#MW-lo. MW-11l PRESSURE GROUT <br /> Q"Other IF' GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTR CTION SPECIFICATIONS <br /> t MONITORING X[]HOLLOW STEM DIA.OF BOREHOLE8 tf Q MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:2 <br /> 0 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS schdl 40 TYPE OF CASING: !]STEEL EF PVC 0 OTHER: <br /> fl VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL2, /1 a, �TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes E[No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Portland <br /> 0 OTHER: a OTHER APPROX.BORING DEPTH 201/2 51 8 BOLTED TRAFFIC BOX or 0 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 /> NG HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby cert' at I have prepa�d thi application and that the work will be done in accordance with San Joaquin <br /> County Or Inan Id egulations, and all applicable California State Laws. <br /> Signe Title/Company Vice President/AGE <br /> Pri Name Robert E. Marty / Date31 October 2007 <br /> DEPARTMENT USE ONLY <br /> SITE AP IN UNIT I E,ADDRESS: <br /> WORK PaN-D TED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> S R# <br /> C-57_ WCC WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6122/04 <br />